†††††††††††††††† DEPARTMENT OF HEALTH AND HUMAN SERVICES
†††††††††††††††††††††† FOOD AND DRUG ADMINISTRATION
†††††††††††††† CENTER FOR FOOD SAFETY AND APPLIED NUTRITION
†††† ††††††††††††††††FOOD ADVISORY COMMITTEE MEETING
Advice on CFSAN'S Draft Report:
Approaches to Establish Thresholds for Major Food Allergens and for Gluten in Food
†††††††††††††††††††††††† Thursday, July 14, 2005
††††††††††††††††††††††††† 8:30 A.M. to 5:20 P.M.
††††††††††††††††††††††††††† Greenbelt Marriott
††††††††††††††††††††††††††††† 6400 Ivy Lane
††††††††††††††††††††††††††††† Grand Ballroom
Greenbelt, Maryland 20770
†††††††††††††††††††††††† P A R T I C I P A N T S
†††††† FOOD ADVISORY COMMITTEE STANDING MEMBERS:
†††††† Richard A. Durst, Ph.D. - Acting Chairman
†††††† Jeffrey A. Barach, Ph.D. (Industry Representative)
†††††† Patrick S. Callery, Ph.D.
†††††† Dennis Gonsalves, Ph.D., M.S.
†††††† Jean M. Halloran (Consumer Representative)
†††††† Douglas C. Heimburger, M.D., M.S.
†††††† Margaret C. McBride, M.D.
†††††† Mark Nelson, Ph.D. (Industry Representative)
†††††† Carol I. Waslien Ghazaii, Ph.D., R.D.
†††††† TEMPORARY VOTING MEMBERS:
†††††† Petr Bocek, M.D., Ph.D. (Absent 7/14/05 Session)
†††††† Margaret Briley, Ph.D., R.D.
†††††† Erica Brittain, Ph.D.
†††††† Ciaran P. Kelly, M.D.
†††††† Soheila June Maleki, Ph.D.
†††††† David O. Oryang
† †††††Marc D. Silverstein, M.D.
†††††† Suzanne Teuber, M.D.
†††††† FOOD AND DRUG ADMINISTRATION:
††††† †Robert E. Brackett, Ph.D. - Director
†††††† Food and Drug Administration, CFSAN
†††††† Catherine Copp, J.D. - Senior Policy Advisor
†††††† Food and Drug Administration, CFSAN
†††††† Steven M. Gendel, Ph.D. - Senior Scientist
†††††† Food and Drug Administration
†††††† National Center for Food Safety and Technology
†††††† Rhonda Kane, M.S., R.D. - Consumer Officer
†††††† Food and Drug Administration, CFSAN
†Marcia Moore, Food Advisory Committee, Executive Secretary
†††††††††††††††††† P A R T I C I P A N T S (Continued)
†††††† FOOD AND DRUG ADMINISTRATION STAFF:
†††††† Michael M. Landa, J.D. - Deputy Director for Regulatory Affairs
†Food and Drug Administration, CFSAN
†††††† Stafano Luccioli, M.D. - Senior Medical Advisor
†††††† Food and Drug Administration, CFSAN
†††††† GUEST SPEAKERS:
†††††† Pekka Collin, M.D., M.P.H. - Professor
† †††††University of Tampere, Medical School, Finland
†††††† Catherine L. Copp, J.D.
†††††† Policy Advisor, CFSAN, FDA
†††††† Alessio Fasano, M.D. - Professor of Pediatrics
†††††† Medicine & Physiology and Director, the Mucosal
†††††† Biology Research Center, Center for Celiac
†††††† Research, University of Maryland School of
†††††† Steven M. Gendel, Ph.D. - Senior Scientist
†††††† National Center for Food Safety and Technology, FDA
†††††† Rhonda R. Kane, M.S., R.D. - Consumer Safety
†††† ††Officer CFSAN, FDA
†††††† Donald Kasarda, Ph.D. - Consultant and Retired
†††††† Senior Scientist, Agriculture Research Service,
†††††† Cynthia Kupper, R.D., C.D. - Executive Director
†††††† Gluten Intolerance Group of North America
†††††† Joseph A. Murray, M.D. - Professor of Medicine
†††††† The Mayo
Clinic of Rochester, Minnesota
†††††††††††††††††††††††††††† C O N T E N T S
†††††† Call to Order and Welcome and Introductions
†††††††††††††††† Richard Durst, Ph.D., Acting Chairman††††††††††† 6
†††††† Use of Gluten Thresholds
†††††††††††††††† Catherine L. Copp, J.D., CFSAN, FDA††††††††††††† 9
†††††† Introduction to Celiac Disease
†††††††††††††††† Joseph Murray, M.D.†††††††††††††††††††††††††††† 11
†††††† Patient Perspectives on Celiac Disease
†††††††††††††††† Cynthia Kupper, R.D., C.D.††††††††††††††††††††† 69
†††††††††††††††† Donald Kasarda, Ph.D., USDA†††††††††††††††††††† 84
†††††† Question and Answer Session††††††††††††††††††††††††††††† 108
†††††† Prospective Studies
†††††††††††††††† Alessio Fasano, M.D.†††††††††††††††††††††††††† 114
†††††† Question and Answer Session††††††††††††††††††† ††††††††††146
†††††† Retrospective Studies
†††††††††††††††† Pekka Collin, M.D., M.P.H.†††††††††††††††††††† 161
†††††† Question and Answer Session††††††††††††††††††††††††††††† 182
†††††† International Perspectives on Gluten-Free
†††††††††††††††† Rhonda S. Kane, M.S., R.D., CFSAN, FDA†††††††† 186
†††††† Question and Answer Session††††††††††††††††††††††††††††† 198
†††††† Public Comments:
†††††††††††††††† Elaine Monarch†††††††††††††††††††††††††††††††† 212
†††††††††††††††† Alice Bast††††††††††††††††††††† †††††††††††††††220
†††††††††††††††† Mary Schluckabeer††††††††††††††††††††††††††††† 225
†††††††††††††††† Tom P. Sullivan††††††††††††††††††††††††††††††† 232
Steve Taylor†††††††††††††††††††††††††††††††††† 240
†††††††††††††††††††††††††††† C O N T E N T S
†††††† Overview of Approaches to Establishing
†††††††† Thresholds: Gluten
†††††††††††††††† Steven M. Gendel, Ph.D.††††††††††††††††††††††† 253
†††††† Question and Answer Session††††††††††††††††††††††††††††† 257
†††††† Committee Discussion:
†††††††††††††††† Panel Discussion with Guest Speakers†††††††††† 259
†††††††††††††††† Gluten and Celiac Disease - FDA Questions††††† 287
†††††††††††††††† Revisit Food Allergens†††††††††††††††††††††††† 354
Richard Durst, Ph.D., Acting Chairman††††††††† 363
†††† †††††††††††††††††††††P R O C E E D I N G S
†††††††††††††† CALL TO ORDER AND WELCOME AND INTRODUCTIONS
†††††††††††††††† CHAIRMAN DURST:† Good morning.† I would
†††††† like to call the meeting to order.† All right, I
†††††† would like to welcome everyone back and also
†††††† welcome new participants in our meeting this
†††††††††††††††† For those of you who weren't here
†††††† yesterday, there is a "Conflict of Interest
†††††† Statement" over on the table, if you want to refer
†††††† to that at all, otherwise I would also ask again
†††††† that maybe our participants or our members of the
†††††† Food Advisory Committee would introduce themselves
†††††† again for the benefit of those who were not here
†††††††††††† ††††I am Dick Durst, professor [of]chemistry at
†††††† Food Science and Technology Department at Cornell
†††††††††††††††† Marc, would you start it off?
†††††††††††††††† DR. SILVERSTEIN:† Marc Silverstein, I'm a
†††††† general internist and geriatrician at Baylor Health
†††††† Care System
†††††††††††††††† DR. TEUBER:† Suzanne Teuber, I am an
†††††† allergist at UC-Davis.
†††††††††††††††† MR. ORYANG:† I am David Oryang.† I am a
†††††† risk analyst and agricultural engineer at the
†††††† United States Department of Agriculture, Animal and
†††††† Plant Health Inspection Service.
†††††††††††††††† DR. KELLY:† Good morning.† Ciaran Kelly, I
†††††† am a gastroenterologist at Harvard Medical School
†††††† in Boston.
†††††††††††††††† DR. MALEKI:† I am Soheila Maleki.† I am a
†††††† scientist with the USDA.
†††††††††††††††† DR. BRITTAIN:† Erica Brittain, I am a
†††††† statistician at the National Institute of Allergy
†††††† and Infectious Disease.
†††††††††††††††† DR. BRILEY:† Margaret Briley, University
†††††† of Texas at Austin, nutritionist.
†††††††††††††††† MRS. MOORE:† Marcia Moore, I am the
†††††† executive secretary for the Food Advisory Committee
†††††† and the Food and Drug Administration.
†††††††††††††††† DR. WASLIEN:† I am Carol Waslien,
†††††† nutritional epidemiologist at the School of
the University of Hawaii.
†††††††††††††††† DR. BRILEY:† I am Margaret McBride, child
†††††† neurologist at Akron Children's Hospital.
†††††††††††††††† DR. CALLERY:† Pat Callery, West Virginia
†††††† University, pharmaceutical scientist.
†††††††††††††††† DR. GONSALVES:† I am Dennis Gonsalves, a
†††††† scientist at USDA.
†††††††††††††††† DR. HEIMBURGER:† I am Doug Heimburger, a
†††††† physician and nutrition specialist at the
†††††† University of Alabama at Birmingham.
†††††††††††††††† DR. BARACH:† Jeff Barach with Food
†††††† Products Association here, in Washington, D.C., in
†††††† regulatory affairs.
†††††††††††††††† DR. NELSON:† Mark Nelson with the Grocery
†††††† Manufacturers Association here, in Washington,
†††††† D.C., and I am responsible for scientific and
†††††† regulatory policy.
†††††††††††††††† MS. HALLORAN:† Jean Halloran with
†††††† Consumers Union located in Yonkers, New York, and I
†††††† am director of food policy initiatives.
†††††††††††††††† CHAIRMAN DURST:† Thank you very much.
† †††††††††††††††I would also like to remind everyone and
†††††† also for
our new people here at the meeting that
†††††† the "Charge" of the Committee is written out on the
†††††† meeting document.† The most important thing is that
†††††† we are focusing on the "Threshold Working Group
†††††† Draft Report on Approaches to Establish Thresholds
†††††† for Major Food Allergens and for Gluten in Food."
†††††††††††††††† We are not here to set any kind of
†††††† thresholds or discuss the labeling of these foods
†††††† for allergens, but strictly to make comments on the
†††††† best approaches to use for setting these
†††††††††††††††† Did I cover everything that we need to?
†††††††††††††††† (No verbal response.)
†††††††††††††††† CHAIRMAN DURST:† In that case, let's begin
†††††† with our first presentation.† This is
†††††† Catherine Copp, the policy advisor for CFSAN, FDA,
†††††† on the use of gluten thresholds.
† †††††††††††††††††††††††USE OF GLUTEN THRESHOLDS
†††††††††††††††† MS. COPP:† I have been asked this morning
†††††† to proceed with discussion on gluten and threshold
†††††† levels for gluten or possible thresholds for gluten
†††††† framework.† It is similar to yesterday.† I simply
†††††† want to
provide you with some context for the
†††††† evaluating the Draft Report portion that addresses
†††††† gluten in food.† This is the hazard of being first.
†††††††††††††††† MS. COPP:† Yesterday, I mentioned the Food
†††††† Allergen Labeling and Consumer Protection Act.
†††††† This is a new law that Congress passed last August.
†††††† Although it focuses primarily on allergens, food
†††††† allergens, Congress also directed FDA to address
†††††† the separate problem of gluten in food.
†††††††††††††††† When I say directed, I mean that Congress
†††††† has mandated that the Agency consider and then
†††††† establish regulations according to a schedule to
†††††† define "gluten-free" for use on food labels and
†††††† also to identify the appropriate use of the term.
†††††††††††††††† As with Allergens, for consumers with
†††††† celiac disease, strict avoidance of gluten at
†††††† levels that will elicit an adverse effect is the
†††††† only means to prevent potentially serious
†††††††††††††††† Accurate, complete and informative
†††††† labeling on foods can help these consumers achieve
goal.† We believe that understanding
†††††† thresholds for gluten and having a sound scientific
†††††† framework for evaluating the existence of such
†††††† thresholds will help FDA develop a definition of
†††††† gluten-free and identify appropriate use of the
†††††† term.† That's it.
†††††††††††††††† Thank you.
†††††††††††††††† CHAIRMAN DURST:† Does anyone have any
†††††† comments or question on Catherine's presentation?
†††††††††††††††† (No verbal response.)
†††††††††††††††† CHAIRMAN DURST:† Okay.† We will move on
†††††† then to the presentation from Dr. Joseph Murray,
†††††† professor of medicine at the Mayo Clinic of
†††††† Rochester, Minnesota, on the introduction to celiac
††††††††††††††††††††† INTRODUCTION TO CELIAC DISEASE
†††††††††††††††† DR. MURRAY:† Good morning, Committee
†††††† Members.† I will be providing a general overview to
†††††† celiac disease.
†††††††† ††††††††DR. MURRAY:† First of all, we will discuss
†††††† what is celiac disease.† We will discuss, briefly,
pathogenesis of the disease; who gets it; what
†††††† the treatment is, at least in a very relatively
†††††† superficial fashion.† We will discuss some of the
†††††† complications and compliance issues of celiac
†††††† disease and a prognosis or future of celiac
††††††† †††††††††DR. MURRAY:† Obviously, yesterday was
†††††† focused on food allergies.† "Celiac disease" is one
†††††† of the food intolerances that is immune-mediated,
†††††† though it is not thought to be IgE-mediated; so, it
†††††† comes into the non-IgE-mediated food intolerances
†††††† that are mediated by an immune response.
†††††††††††††††† DR. MURRAY:† Where does it happen?† It
†††††† happens within the smaller intestine, predominantly
†††††† the proximal, smaller intestine is the workhorse of
†††††† the digestive system.† It is this surface of the
†††††† intestinal lining that is maximally expanded by the
†††††† development of circular folds and on top of these
†††††† circular folds the so-called "villi," these villi,
†††††† shown here in a histological picture, which
the digestive surface area.
†††††††††††††††† It is on the surface entrocytes of these
†††††† villi that most of the enzymes and in the layer
†††††† immediately above that in the lumen where most
†††††† digestion of the macromolecules from nutrition are
†††††† broken down and then absorbed.† This is just a
†††††† picture.† It looks like one of those shag-ply
††† †††carpets from the 1970s.† This is a normal
†††††††††††††††† DR. MURRAY:† However, celiac disease is an
†††††† inflammatory state of the small intestinal mucosa.
†††††† It occurs in those who are genetically predisposed,
†††††† and it resolves, the damage resolves, with
†††††† exclusion of dietary gluten.
†††††††††††††††† Here, on the left, is a normal intestine
†††††† with a normal villus structure; and on the right,
†††††† fully evolved celiac disease with complete
†††††††††††††††† The villi are gone, not only are they gone
†††††† but this entire intestinal mucosa is greatly
†††††† thickened and filled with inflammatory cells.† This
†††††† is where
the primary site of injury occurs in
†††††† celiac disease.
†††††††††††††††† I didn't mention it, but it is a permanent
†††††† condition.† While it will heal most of the time
†††††† with exclusion of gluten, the intolerance to gluten
†††††† is permanent and will recur when the individual is
†††††† reexposed to gluten.
†††††††††††††††† DR. MURRAY:† Now, what causes celiac
†††††††††††††††† DR. MURRAY:† We know there are two major
†††††† components to this disease: the first is the
†††††† genetic background of predisposition.
†††††††††††††††† Much of that predisposition revolves in
†††††† the HLA type, which is part of our human leucocyte
†††††† antigen-recognition system.† It is how we determine
†††††† self- and non-self and generate an immune response
†††††† as appropriate and its interaction with
†††††† environmental factors, primarily the environmental
†††††† factor of gluten.
† †††††††††††††††These two conspire together to produce an
response that becomes out of control
†††††† resulting in inflammation, which we just showed to
†††††† you, that occurs primarily in the proximal small
†††††† intestine and then subsequently the consequences of
†††††† this inflammation leading to malabsorption and
†††††††††††††††† DR. MURRAY:† What do we know about the
†††††† genetics of the disease?† For many years, we know
†††††† there is a strong, familial predisposition to the
†††††††††††††††† If you are unlucky enough to be a
†††††† monozygous twin of somebody affected with celiac
†††††† disease, your concordance rate is 80 percent.† It
†††††† is not 100 percent, but it is about 80 percent.† If
†††††† you are a sibling of a celiac, your chance of
†††††† having it is 10 percent.† If you are a child of,
†††††† about 5 to 10 percent.
†††††††† ††††††††There is a very strong association with
†††††† certain HLA molecules.† These are Class II MHC
†††††† molecules but particularly two types.† First, DQ2
†††††† is the predominant type that is required for celiac
and in some populations DQ2 is also an
†††††† enabling type.
†††††††††††††††† These genes, however, while they are
†††††† essentially required for the disease, are not
†††††† sufficient alone to the development of the disease.
†††††† Probably 30 to 40 percent of the Caucasian
†††††† population carry one or both of these molecules,
†††††† but most of them don't get celiac disease.† There
†††††† are other HLA genes that are likely involved,
†††††† though they have not been well elucidated and
†††††† certainly not confirmed in many populations.
†††††††††††††††† There are other chromosomal disorders --
†††††† Down's syndrome, Turner's syndrome, and Williams
†††††† syndrome -- that are associated with a greatly
†††††† increased risk of developing celiac disease for
†††††† reasons that are not entirely clear, but probably
†††††† are associated with the increase risk of disease in
†††††† those chromosomal disorders.
††† †††††††††††††DR. MURRAY:† Looking at the primary
†††††† environmental trigger for the disease -- that is,
†††††† gluten -- it is basically the storage proteins that
†††††† come from
these particular cultivated grasses:
†††††† wheat, barley, rye, and other similar grains from
†††††† within those families.† Other grasses -- for
†††††† example, rice, items such as corn, sorghum, millet,
†††††† and probably not even oats -- are not involved in
†††††† triggering the disease.
†††††††††††††††† DR. MURRAY:† It is the storage proteins
†††††† from the endosperm compartment of the wheat kernel
†††††† particularly, and those are gliadins oar glutenins
†††††† that are thought to contain the antigenic moieties
†††††† that trigger the disease.
†††††††††††††††† DR. MURRAY:† What is it about these wheat
†††††† proteins?† Well, if you take wheat, as an example
†††††† of the others, these storage proteins are uniquely
†††††† high in certain amino acids, especially glutamines
†††††† and prolines.
†††††††††††††††† Over 30 percent of the amino acids in
†††††† gliadin are glutamines.† The glutamines, of course,
†††††† can be cross-linked to give the grain its
†††††† resiliency.† Really the cooking ability, the
†††††† ability to
use wheat as such an effective way of
†††††† making things that stick together like bread, for
†††††† example, and maintain their shape, is largely a
†††††† property of these particular combinations of amino
†††††††††††††††† The proline sequences that contain or
†††††† proline residues contained within the wheat
†††††† proteins also appear to form helices, and these
†††††† helices are resistant to digestion within the
†††††† mammalian gut.
†††††††††††††††† DR. MURRAY:† This may be a key factor in
†††††† what results in the likelihood of these peptides
†††††† basically being maintained and becoming, then,
†††††† still available for the immune system to recognize
†††††† in a patient with celiac disease.
†††††††††††††††† Now, gliadin molecules are presented by
†††††† these HLA types to T-cells in the intestine, and
†††††† T-cells that are specifically primed to respond to
†††††† gluten.† There are certain gliadin molecules that
†††††† have a higher affinity than others for these
†††††† Class II molecules and then the T-cell receptor.
††††††† †††††††††These peptides may be processed or
†††††† within the gut, perhaps, to make them more
†††††† antigenic.† They may not start out very antigenic,
†††††† but then they undergo some change within the gut
†††††† that may make them more antigenic.
†††††††††††††††† It turns out that some of these peptides
†††††† that are particular immunodominant, these are the
†††††† ones that are most likely to produce an immune
†††††† response, that those immunodominant peptides may be
†††††† digestion resistant because they contain those
†††††† proline sequences that perform helix, making them
†††††† relatively poorly digestible by peptidases within
†††††† the gut.
†††††††††††††††† DR. MURRAY:† Now, it turns out that there
†††††† is a contribution to this antigenic nature from
†††††† within the intestine itself, and this may well be
†††††† because of this enzyme tissue transglutaminase.
††††††††††††† †††This is an enzyme that is present within
†††††† the gut mucosa.† It is released by cells,
†††††† especially fibroblasts when they become inflamed,
†††††† and it cross-links cystine residues.
It turns out that it will also act on
†††††† gliadin by deamidating some of those glutamine
†††††† residues, some specific glutamine residues, to
†††††† glutamates, making it more antigenic by deamidating
†††††† that gliadin peptide and making it fit more
†††††† perfectly or with a tighter affinity into the
†††††† binding groove of the DQ2-HLA molecule, and, hence,
†††††† producing a more vigorous immune response within
†††††† the gut.
†††††† ††††††††††DR. MURRAY:† This is a schema, a
†††††† relatively simplified schema, of what I have just
†††††† talked about.† We start with wheat.† You look at
†††††† particularly the ethanol-soluble fraction, and
†††††† gliadin is probably broken up into smaller
†††††† peptides, but still of a sufficient size to produce
†††††† an immune response.
†††††††††††††††† It is taken up across the epithelium
†††††† presented by antigen presenting cells to the
†††††† T-cells.† These are T-cells that will specifically
†††††† respond to gluten then producing two types of
†††††† responses: a cellular response, characterized by
producing interferon gamma and possibly
†††††† other cytokines.† It is probably the cellular
†††††† response that leads to the "inflammatory cascade"
†††††† that produces the damaged epithelium characteristic
†††††† of celiac disease.
†††††††††††††††† It also produces help to the B-cell side,
††† †††to produce plasma cells that produce antibodies.
†††††† These antibodies are directed both against the
†††††† exogenous antigen gliadin and also antibodies
†††††† against tissue transglutaminase or what was known
†††††† as an the endomysial antibody.† It is not known
†††††† what the actual pathogenic role of this is, but it
†††††† is a very useful serologic or blood marker for the
†††††††††††††††† I mentioned about the antigen getting
†††††† changed by tissue transglutaminase.† This is a
†††††† little cartoon which shows the peptide derived from
†††††† gluten.† If you change one specific glutamine to a
†††††† glutamic acid, which could be done by tissue
†††††† transglutaminase, this then binds much more
†††††† tightly.† This is the HLA molecule here on the
†††††† surface of the antigen presenting cell, and it fits
perfectly into the T-cell receptor, producing
†††††† a more potent T-cell response.
†††††††††††††††† DR. MURRAY:† Now, there are other things
†††††† that happen in the setting of celiac disease, and I
†††††† am really touching just on the surface of many of
†††††† these, but there are other things that result in
†††††† this inflammation that damage the lining of the
†††††††††††††††† For example, there are metallic proteases
†††††† that damage the structural elements that maintain
†††††† the structure that maintain villus structure.
†††††† There is endothelial injury that occurs affecting
†††††† the blood vessels in the villus.† There are
†††††† antibodies, autoantibodies, that are produced that
†††††† affect actin that are involved in the site
†††††† maintaining the structure of the entrocyte itself.
†††††††††††††††† DR. MURRAY:† Recently, there has been work
†††††† suggesting that there is a molecule called
†††††† "zonulin" that may be released in the setting of
†††††† celiac disease.
††††††††††† †††††This is important because it opens up
†††††† tight junctions between entrocytes which may allow
†††††† even more ready access of the antigen, the foreign
†††††† antigens, between the cells into lamina propria
†††††† where antigen-presenting cells can then present
†††††† those peptides to the gluten-responsive T-cells,
†††††† further accelerating the disease.
†††††††††††††††† DR. MURRAY:† Now, I pointed out that many
†††††† people, 30 percent or more of the Caucasian
†††††† population, carry DQ2 or DQ8.† Virtually, the
†††††† entire population are exposed to gluten, but most
†††††† people don't get the disease.
†††††††††††††††† There must be triggers that produce the
†††††† disease.† There is evidence that suggests that
†††††† gluten in the infant diet, specifically the age of
†††††† introduction of gluten into the infant's diet, may
†††††† be important in triggering or at least producing
†† ††††autoantibody markers suggestive of celiac disease
†††††† early in life.
†††††††††††††††† It is not clear, however, if that changes,
†††††† whether you delay introduction or not whether that
the lifetime risk of celiac disease, but
†††††† it certainly seems to be important in triggering or
†††††† producing evidence in childhood at least of celiac
†††††† disease immune markers.
†††††††††††††††† The amount of gluten in the child's diet
†††††† may be important.† There are other events such as
†††††† pregnancy, infection, or surgeries that may bring
†††††† previously asymptomatic celiac disease to clinical
††††††† †††††††††DR. MURRAY:† One could speculate, and I
†††††† think this is based on some data, putting data
†††††† together, that one's risk for celiac disease starts
†††††† with your HLA type.† Only those who carry HLA types
†††††† are at risk.† You, then, are exposed to gluten.
†††††† Perhaps the timing of exposure is important,
†††††† developing in some individuals a sensitivity to
†††††††††††††††† Then, with the interaction of other
†††††† factors such as other genes other than HLA, other
†††††† things that may predispose one to autoimmunity
†††††† including gender and other events that may occur --
gastroenteritis, aging, postsurgical or postpartum
††††† †changes in the immune system that may occur -- may
†††††† lead to a loss of tolerance, inflammation, and
†††††† subsequent malabsorption.
†††††††††††††††† DR. MURRAY:† Don Kasarda, who is here once
†††††† used the term or suggested that celiac disease was
†††††† a collision between our evolution of our immune
†††††† system and our ability to recognize self and
†††††† non-self through the HLA system and our cultivation
†††††† of wheat and these other grasses.† This collision
†††††† occurs in the intestine.
†††††††††††††††† DR. MURRAY:† Now, when this collision
†††††† occurs and results in damage, how does it present?
†††††† And who gets the disease?
†††††††††††††††† DR. MURRAY:† Well, this is classic celiac
†††††† disease, and this is the way that I certainly
†††††† learned about celiac disease.† A severe
†††††† malnourished child with evidence of malnutrition
†††††† often associated with the large, swollen abdomen
†††††† but great
muscle, terrific muscle, wasting and
†††††† protein-calorie malnutrition with symptoms that
†††††† would occur sometime after the onset of gluten
†††††† introduction into the diet, sometime between the
†††††† age of six months and seven years of age: with
†††††† failure to thrive; abdominal distention; anorexia;
†††††† diarrhea; steatorrhea, that is the passage of
†††††† malabsorptive stools laden with fat; anemia; growth
†††††† failure; and vitamin deficiencies.† That was really
†††††† the picture that we had of celiac disease 30 years
†††††††††††††††† DR. MURRAY:† However, we now see celiac
†††††† disease in adulthood.† In fact, celiac disease can
†††††† present at any age.† Symptoms can include things
†††††† such as abdominal pain, even upper-GI symptoms:
†††††† heartburn, nausea, vomiting, anemia, fatigue.
†††††††††††††††† There are of course patients who have
†††††† symptoms of malabsorption, though not necessarily
†††††† the classic, fully evolved malabsorptive picture.
†††††† Steatorrhea as a presenting symptom is relatively
†††††† rare, even patients may have constipation.
†††††††††††††††† DR. MURRAY:† It can mimic other disorders
†††††† such as lactose intolerance.† Indeed, lactose
†††††† intolerance may be secondary to the damage caused
†††††† by celiac disease.† It may mimic the symptoms of
†††††† irritable bowel syndrome or symptoms of
†††††† inflammatory bowel disease.
†††††††††††††††† DR. MURRAY:† There are specific
†††††† deficiencies that can occur in celiac disease,
†††††† especially the fat-soluble vitamins -- D, E, A,
†††††† and K -- with their resultant syndromes from
†††††††††††††††† Iron deficiency is especially common in
†††††† celiac disease because iron is absorbed in the
†††††† proximal small intestine; folate deficiency, again,
†††††† because it is absorbed in the proximal small
†††††† intestine; and, interestingly, B12 deficiency may
†††††† be relatively common in celiac disease by a variety
†††††† of mechanisms.† Other trace elements -- zinc, B6,
†††††† selenium, and others -- may also be deficient in
†††††† celiac disease.
While in the past we would look for
†††††† combinations of these, often a patient would
†††††† present with many of these deficiencies at the time
†††††† of diagnosis, now it is relatively uncommon to see
†††††† the entire spectrum of deficiencies.† Indeed, you
†††††† usually see one or two deficiencies that are
††† †††clinically evident, and the others may not even be
†††††††††††††††† DR. MURRAY:† How about non-intestinal?† I
†††††† have mentioned that the major site of injury is in
†††††† the gut, but there are patients who will present
†††††† with non-intestinal presentations which can involve
†††††† into things such as the musculoskeletal system,
†††††† joint pains and osteoporosis or osteomalacia;
†††††† infertility or reproductive issues, delayed
†††††† puberty, spontaneous recurrent abortions have been
†††††† described; hematologic, which is predominantly
†††††† anemia; hyposplenism is an unusual consequence but
†††††† can present; and then dentition, enamel defects,
†††††† can be a presenting feature.
DR. MURRAY:† To focus on iron
†††††† anemia, which is probably one of the most common
†††††† reasons that I see celiac disease, about 5 to 8
†††††† percent of adults who present with unexplained iron
†††††† deficiency in some studies have celiac disease.
†††††††††††††††† It is especially common in those who are
†††††† resistant to the use of oral iron.† If you look at
†††††† individuals who are coming to gastroenterologists
†††††† for endoscopy, it may be 5 to 15 percent of those
†††††† patients, depending on the study, who may have
†††††† celiac disease if biopsies are taken from the small
†††††††††††††††† However, many of those patients are even
†††††† missed because the biopsies are still not taken
†††††† during routine endoscopy in patients who have got
†††††† anemia in about a third to a half of patients.
†††††††††††††††† DR. MURRAY:† Osteomalacia or bone disease,
†††††† this is an example of severe disease with
†††††† pseudofractures in the pelvis of an individual,
†††††† whose only presentation was osteomalacia with no GI
†††††† symptoms, caused by celiac disease.
†††† ††††††††††††Other non-intestinal presentations
†††††† neurologic or even neuropsychiatric syndromes such
†††††† as neuropathy, ataxia, seizures, cognitive decline,
†††††† or dementias; fibromyalgia-like syndromes or
†††††† chronic fatigue syndrome-like presentations;
†††††† individuals with skin and mucous membranes, there
†††††† is a specific rash associated with celiac disease,
†††††† a recurrent aphthous ulceration of the mouth; the
†††††† dental enamel defects we mentioned.
†††††††††††††††† DR. MURRAY:† And, then, dermatitis
†††††† herpetiformis was specifically mentioned, because
†††††† this very blistering, extremely itchy skin rash
†† ††††that affects the extensor surfaces is a direct
†††††† manifestation of intestinal gluten sensitivity.
†††††††††††††††† DR. MURRAY:† Now, what about other
†††††† associated conditions?† Celiac disease is
†††††† associated with other autoimmune conditions.† It
†††††† may be seen in 3 to 7 percent of Type I diabetics,
†††††† individuals with thyroid disease, individuals with
†††††† inflammatory arthritis, primary biliary cirrhosis,
†††††† as examples
of others; and then the congenital
†††††† disorders, especially those associated with
†††††† chromosomal abnormalities and also selective IgA
†††††† deficiency.† If you look at relatives of celiacs,
††† †††it is anywhere between 5 to 20 percent, depending
†††††† on how one is related to someone with celiac
†††††††††††††††† DR. MURRAY:† Now, beyond the symptomatic
†††††† celiac disease, there are also individuals who have
†††††† no symptoms, who already have fully evolved damage
†††††† within their intestine, and there may be no symptom
†††††† or there may not be occurring in someone with an
†††††† associated disease.
†††††††††††††††† This is frequent to find this in first-
†††††† and second-degree relatives of patients with celiac
†††††††††††††††† DR. MURRAY:† There is also what is termed
†††††† "latent" -- well, whether it is latent celiac
†††††† disease or latent gluten sensitivity -- individuals
†††††† who have a positive serologic response but have a
small-bowel biopsy.† Some of those
†††††† patients will go on to develop the full-blown
†††††† disease, if followed, on a normal diet.
†††††††††††††††† DR. MURRAY:† What about the epidemiology?
†††††† To summarize, while it was first identified in
†††††† Europe, it occurs essentially in all populations,
†††††† which could be termed Caucasian.† Its prevalence is
†††††† probably somewhere between 1 in 90 to 1 in 300;
†††††† however, the diagnosis rate is much lower, which
†††††† would suggest a prevalence of about 1 in 2,000, if
†††††† you just look at the diagnosed cases.
†††††††††††††††† It is one of the most frequent genetically
†††††† based diseases.† If you look at other countries --
†††††† Latin America, or other areas; Africa, especially
†††††† North Africa; if you look at Asian countries --
†††††† there is celiac disease present in those.† The
†††††† worldwide average prevalence is somewhere very
†††††† close to 1 percent.
†††††††††††††††† DR. MURRAY:† I'm coming a little closer to
†††††† home.† This is the data from Olmsted County, that
published a couple of years ago, which looked at
†††††† the new case identification or the incidence rate.
†††††††††††††††† The solid yellow line is the new cases per
†††††† 100,000 in the population, which is essentially
†††††† quite low and stable over many decades until the
†††††† 1990s and into 2000 to 2001, showing a greatly
†††††† increased rate of detection of celiac disease.
†††††††††††††††† If we looked at who were being diagnosed,
†††††† this is the age of diagnosis by age category.† This
†††††† is the incidence per 100,000 of people in that age
†††††† category in the community.† You can see that the
†††††† new cases being diagnosed are predominantly people
†††††† between the age of 45 and 64.
†††††††††††††††† The solid line indicates females; so,
†††††† females are diagnosed at a rate about twice that of
†††††† males of all ages.
†††††††††††††††† There are a significant portion of
†††††† individuals, almost a third, who were diagnosed for
†††††† the first time over the age of 65.
†††††††††††††††† DR. MURRAY:† One can term or consider
†††††† celiac disease like an iceberg.† These are a series
†††††† of icebergs
where the tip of the iceberg is the
†††††† part that has been detected, and the part
†††††† underwater is the part that can be found if one
†††††† screens the population.† Of note, these are numbers
†††††† per thousand not percent.
†††††††††††††††† Obviously, there are some places like
†††††† Ireland, for instance, which is quite a big iceberg
†††††† with a lot above water but also a lot below water.
†† ††††Finland, which this iceberg is probably even more
†††††† out of the water as they have got a very active
†††††† program for finding celiac disease.
†††††††††††††††† This is circa 1996.† The U.S.A. iceberg is
†††††† still close to a very low level of actually being
†††††† diagnosed; but this number, the part underwater,
†††††† has actually grown to be something very close to
†††††† what you would find in Finland or Ireland,
†††††† especially when one looks at, at least what we know
†††††† about is really from a Caucasian population.
†††††††††††††††† DR. MURRAY:† One miniature study, this is
†††††† one we simply looked at, Natrona County in Wyoming.
†††††† This is a very isolated community.† Anybody who has
†††††† been to
Wyoming, there is lots of nothing for miles
†††††† and miles.
†††††††††††††††† We were able to study about 4,000
†††††† individuals from a health fair, generally healthy,
†††† ††and found the numbers above just under 1 percent of
†††††† people who had serologic evidence for celiac
†††††††††††††††† Only half of them had GI symptoms.† Most
†††††† of them did not have other risk factors for celiac
†††††† disease, just two having family members with celiac
†††††††††††††††† However, these are numbers that would
†††††† confirm basically the rest of the world's data that
†††††† suggests that the prevalence of celiac disease, if
†††††† you look for it, is probably slightly under
†††††† 1 percent.
†††††††††††††††† DR. MURRAY:† Now, how does one make the
†††††† diagnosis?† It starts with suspicion.† Serologic
†††††† tests may be very effective at detecting the
†††††† disease.† The intestinal biopsies are regarded as
†††††† the gold standard.† Then, one ultimately gets a
†††††† response to
a gluten-free diet to confirm the
†††††††††††††††† DR. MURRAY:† The pathology, as we have
†††††† mentioned already, is a pathology of chronic
†††††† inflammation within the intestine with features
†††††† such as intraepithelial lymphocytes on the surface,
†††††† villus atrophy or the loss of the villus surface,
†††††† great crypt hyperplasia, and then characterized by
†††††† being a lamina propria filled with lymphocytes,
†††††† macrophages, plasma cells, and even eosinophils.
††††††† †††††††††DR. MURRAY:† There is however a spectrum
†††††† of damage that occurs, typified here by the Marsh
†††††† classification.† This is classic disease, but there
†††††† are also milder forms of the disease that may be
†††††† asymptomatic in most individuals.
†††††††††††††††† DR. MURRAY:† Our algorithm for finding
†††††† celiac disease, if we have a high clinical
†††††† suspicion, an individual with malabsorption, we
†††††† biopsy those individuals.† If we have an individual
†††††† who is at
moderately increased risk, serology is
†††††† probably the most effective way of finding it.
†††††† Though, we yet do not depend on the serology alone
†††††† to detect this, there are other circumstances for
†††††† alternate; serologic testing may be necessary.
†††††††††††††††† DR. MURRAY:† Now, what about treatment for
†††††† celiac disease, or, as one patient with celiac
†††††† disease called it, "playing gluten-free roulette"?
†††††††††††††††† DR. MURRAY:† The nuts and bolts of a
†††††† gluten-free diet, basically one needs to avoid
†††††† foods that contain the offending grains: wheat,
†††††† barley, rye, and the wheatlike grains of spelt and
†††††††††††††††† I put down at the bottom that many corn or
†††††† rice commercial cereals do not appear to be
†††††† gluten-free because of their incorporation of
†††††† particularly barley extract in their flavor
†††††††††††††††† DR. MURRAY:† Now, one of the issues and of
†††††† course the
issue for today is, How much gluten is
†††††† too much?† We will be hearing a lot more when you
†††††† hear prospective and retrospective data later this
†††††† morning on this.† I am not going to dwell on it.
†††††††††††††††† One thing from clinical appreciation is
†††††† that symptoms are not a good indicator of gluten
†††††† ingestion.† Many patients can have significant
†††††† damage to their intestine, despite the absence of
†††††† symptoms when they ingest gluten.
†††††††††††††††† Most patients diagnosed clinically with
††† †††celiac disease have never suspected that wheat or
†††††† gluten products are what are precipitating their
†††††† symptoms.† They may have or are often likely to
†††††† have blamed other foods that they weren't able to
†††††† digest because of the damage.
†††††††††††††††† Antibodies such as tissue transglutaminase
†††††† antibodies are really only positive of the
†††††† substantial gluten contaminating the diet.† At
†††††† least in my practice if somebody admits to cheating
†††††† more than once a month they will like continue to
†††††† have injury in their gut.† However, there is a high
†††††† degree of variability in the sensitivity to gluten
at least clinically.
†††††††††††††††† DR. MURRAY:† We will hear a little bit
†††††† about Codex Alimentarius draft standards.† This,
†††††† however, is still a draft, I think a Stage IV
†††††† draft.† I want to put this up really to demonstrate
†††††† that there is a variance between countries and what
†††††† one allows.
†††††††††††††††† We will hear more from our colleagues from
†††††† Europe about some of the incorporation of rendered
†††††† gluten-free foods which use the gluten-containing
†††††† grains as a base and then remove the proteins from
†††††††††††††††† DR. MURRAY:† What about non-responsive
†††††† celiac disease?† This is relatively common.† By
†††††† far, the most common reason is inadvertent gluten
†††††† contamination of the diet and lymphocytic colitis,
†††††† pancreatic insufficiency, bacterial overgrowth, and
†††††† then only a few patients have true refractory
†††††† disease that no longer responds to exclusion of
† †††††gluten from the diet.
†††††††††††††††† DR. MURRAY:† There are many potential
†††††† sources of contamination of the diet with gluten,
†††††† which include of course commercial cereals, eating
†††††† out, communion wafers, lipstick, airborne flour or
†††††† starch in certain work situations, so-called "soy"
†††††† sauces made from wheat, mislabeled or unlisted
†††††† ingredients have been an issue, and at least
†††††† allegedly some medications.
†††††††††††††††† DR. MURRAY:† Some ingredients that people
†††††† are concerned about: seasonings and spice blends,
†††††† modified food starch, malt and malt extract,
†††††† modified hop extract or yeast-malts, sprout
†††††† extract, dextrins, caramel color.† There are a
†††††† whole bunch of things that might be derived from
†††††† gluten-containing grains.
†††††††††††††††† DR. MURRAY:† What about complications
†††††† associated with untreated celiac disease?† We know
†††††† the mortality of symptomatic celiacs who do not
†††††† comply with the diet has doubled.† The mortality of
disease even when it is diagnosed is also
†††††† double, even following out for several years after
†††††† the diagnosis.
†††††††††††††††† The predominant excess in death comes from
†††††† GI malignancies.† There are also morbidity
†††††† consequences such osteoporosis or osteomalacia,
†††††† stunted growth, infertility, chronic ill-health --
†††††† all of which could be prevented by early detection
†††††† and treatment.
†††††††††††††††† DR. MURRAY:† What are the dangers of
†††††† non-compliance?† The increased mortality we
†††††† discussed, the osteoporosis.† Children who were
†††††† diagnosed and then did not remain on a gluten-free
†††††† often have osteoporosis or diminished bone density
†††††† when they get to adulthood, lymphoma, other
†††††† cancers, and then the psychological effects of
†††††††††††††††† DR. MURRAY:† One of the most feared
†††††† complications of this are the T-cell lymphoma.
†††††† This is celiac disease on this side, and the T-cell
†††††† lymphoma on
the other side is one of the more
†††††† feared complications with a very high mortality.
†††††††††††††††† DR. MURRAY:† However, as I pointed out,
†††††† most celiac disease is probably not symptomatic, at
†††††† least when we look at a cross-section of the
†††††† population.† We do not know whether those
†††††† identified by screening are less sick than
†††††† clinically diagnosed celiac disease.
†††††††††††††††† We don't know the benefit or negative
†††††† effects of a gluten-free diet in those who are
†††††† found by screening alone.† We don't know if they
†††††† are any more or less likely to comply with a
†††††† gluten-free diet.† We don't know whether
†††††† intervening in those patients will actually affect
†††††† their ultimate mortality.
†††††††††††††††† DR. MURRAY:† George Dennison Prentice
†††††† said, "What come call health, if purchased by
†††††† perpetual anxiety about diet, isn't much better
†††††† than tedious disease."
DR. MURRAY:† This comes to the
†††††† There is, I think, a promising future in celiac
†††††† disease, a variety of approaches, which I have
†††††† listed, that individuals and research groups are
†††††† looking at as alternates to the gluten-free diet,
†††††† though none of them are really even close to
†††††† clinical use.
†††††††††††††††† DR. MURRAY:† This is one that has been
†††††† tested in patients using a lactobacillus digestion
†††††† strategy, trying to reduce the potential, harmful
†††††† effects of gluten.
†††††††††††††††† In summary, I would like to suggest that
†††††† gluten or celiac disease is common.† It has been
†††††† largely unrecognized until recently.† There are
†††††† many challenges that face patients and their
†††††† physicians in the treatment.
†††††††††††††††† The gluten-free diet is not simple.† There
†††††† is widespread use of grain proteins in good, and
†††††† that makes it challenging for individuals with
†††††† celiac disease.† Food ingredient source
†††††† identification is of great concern to patients.
Dietitians and those who counsel patients
†††††† with celiac disease, we are here because of
†††††† regulation or potential regulations.† Defining
†††††† acceptable thresholds and verification of those may
†††††† be very important to patients with celiac disease.
†††††††††††††††† DR. MURRAY:† I finish with an aside on
†††††† another food safety issue, an invitation to come to
†††††† Minnesota and enjoy Joe's and have worms at the
†††††† same time.
†††††††††††††††† Thank you.
†††††††††††††††† CHAIRMAN DURST:† Thank you very much,
†††††† Dr. Murray.
†††††† QUESTION-AND-ANSWER SESSION
†††††††††††††††† CHAIRMAN DURST:† I would like to ask the
†††††† Committee if they have any questions or discussion,
†††††† and also to point out that Dr. Murray will not be
†††††† able to stay around for discussion this afternoon.
†††††† If there are questions, now is the time to ask
†††††††††††††††† DR. HEIMBURGER:† Thank you very much for
presentation.† It is very helpful.† I do care
†††††† for some patients with celiac disease.† As you
†††††† already mentioned, one of the big questions that
†††††† they have is, "What really are my risks if I play
†††††† with it a little bit?† If I knowingly introduce a
†††††† little bit of gluten in my diet, how absolutely
†††††† obsessive do I need to be about it?"
†††††††††††††††† With the mortality being primarily
†††††† associated with the risk of lymphoma, what is the
†††††† quality of the evidence that compliance with gluten
†††††† restriction is really correlated with the risk of
†††††††††††††††† DR. MURRAY:† The evidence, the quality of
†††††† the evidence is largely observational, taking
†††††† cohorts and following them, and often their
†††††† self-assessment of their level of compliance.† The
†††††† data is based on those cohorts.† They are
†††††† predominantly referral cohorts.
†††††††††††††††† The longest follow up comes from Britain.
†††††† In those, there is quite a clear increased risk not
†††††† just for lymphoma but other malignancies in those
†††††† who are considered not to be completely compliant
†††††† with the
diet.† I would say the level of evidence
†††††† while it is not a prospective study, in retrospect
†††††† in fact it appears to be reasonably strong.
†††††††††††††††† DR. BRILEY:† Margaret Briley.† I would
†††††† like to know what you can tell us what might be the
†††† ††reason for the increased detection of celiac
†††††† disease?† Is the serological test the definitive
†††††† reason?† What is going on with those?† It seems to
†††††† be more prevalent, as you said, in our society.
†††††††††††††††† DR. MURRAY:† I think there are probably
†††††† two reasons, one is probably serologic detection
†††††† has made this an acceptable diagnosis to primary
†††††† care physicians, number one; and the second is
†††††† suspicion, that is, the awareness of celiac disease
††† †††as a possibility.
†††††††††††††††† I do not believe, however, we can rule out
†††††† the possibility that celiac disease is actually
†††††† increasing in prevalence over time.
†††††††††††††††† We don't know, but we know that there
†††††† certainly were substantial increases in other
†††††† inflammatory bowel diseases over the last 50 years,
†††††† which may not have been accounted for by detection
†††††† rates, for
† †††††††††††††††I do agree with you it is probably the
†††††† sero-detection.† It is a combination of those two
†††††† things, suspicion and ease of detection have made
†††††† the biggest difference.† However, I would not rule
†††††† out the possibility of its actually increasing in
†††††††††††††††† CHAIRMAN DURST:† Soheila.
†††††††††††††††† DR. MALEKI:† Soheila Maleki.† I was
†††††† wondering how long does a person that is
†††††† asymptomatic go before they find they are
†††††† symptomatic?† How do they usually find out?
†††††††††††††††† DR. MURRAY:† First of all, we don't know
†††††† when it starts.† There is one study I didn't talk
†††††† about from Denver that suggested that children, if
†††††† you follow children at genetic risk for celiac
†††††† disease based on HLA type, that they will convert,
†††††† sero convert, by about the age of seven, though
†††††† most of them are asymptomatic.
†††††††††††††††† It reaches all but 1 percent of that
†††††† childhood cohort, the same prevalence you find if
†††††† you look at adults.† The suggestion is that you
developed that celiac autoimmunity probably by
†††††† the age of seven.
†††††††††††† ††††However, the age, the median age, of
†††††† diagnosis is 45 years of age.† It is likely that
†††††† those individuals have some clinical disease for a
†††††† long time before they present.
†††††††††††††††† In our population, the most common reason
†††††† for presentation is postmenopausal anemia.† Women
†††††† who have anemia sometimes go a long time,
†††††† especially when they are menstruating.† The doctor
†††††† says that menstruating is an excuse for the anemia.
†††††† Now that they are menopausal and are no longer
†††††† menstruating they no longer have an excuse for
†††††† their anemia, and they are referred for evaluation
†††††† for the cause of anemia.
†††††††††††††††† Iron deficiency anemia at least is one of
†††††† the most common, but there are other things.† For
†††††† example, the development of chronic GI symptoms.
†††††† Largely, as the earlier questioner said, probably
†††††† awareness of the possibility of this disease, with
†††††† primary care doctors using sero-diagnosis to find
†††††† celiac disease.
There a lot of atypical symptoms.†
†††††† are reservoirs of celiac disease, the Type I
†††††† diabetics, the family members of celiacs, those
†††††† with chromosomal disorders.† As the doctors looking
†††††† after those people become more aware of celiac
†††††† disease, they are testing their patients more.
DR. BRILEY:† Could you speak a little bit more about
†††††† the evidence that you have in regard to physicians
†††††† using the serological test?† Is it a pretty common
†††††† thing to do it at the very beginning of a patient's
†††††† coming in with GI problems, or is it more likely it
†††††† is down the road a while?
†††††††††††††††† DR. MURRAY:† If you look at the data on
†††††† patientsí presentation time, from presentation to
†††††† diagnosis of celiac disease, it is somewhere
†††††† between 8 and 11 years from the time they present
†††††† to their physician with a complaint to the time
†††††† their diagnosis is made.
†††††††††††††††† I think that time period is now beginning
†††††† to shorten, thankfully.† The serology is done close
†††††† to the end of that period, so it is often only when
†††††† the suspicion is generated.† Partly that is because
†††††† it is not
considered at the early differential
†††††† diagnosis of celiac disease.
†††††††††††††††† It is also difficult.† It is difficult
†††††† because the symptoms are not very specific.
†††††† Fatigue and some bowel disturbance and a little
†††††† anemia, that is not a rare syndrome or not a rare
†††††† collection of symptoms you will see in individuals
†††††† in our community.† It is hard to know where you
†††††† look for celiac disease and when you look for it.
†††††† It is often a very delayed diagnosis.
†††††††††††††††† DR. BRILEY:† Is the serological test one
†††††† that is pretty accurate?† Could one count on it if
†††††† you did it early?
†††††††††††††††† DR. MURRAY:† If you use the more modern
†††††† autoimmune tissue transglutaminase test, for
†††††† example, it is reasonably good.† It is not perfect,
†††††† but it is quite efficient at detecting celiac
†††† ††disease at that level, in that period.† It is not
†††††† perfect, though, but it is a pretty good test.
†††††††††††††††† DR. BRILEY:† It sounds like we need to do
†††††† some education, then.
†††††††††††††††† DR. HEIMBURGER:† A follow up to that --
Heimburger -- what is currently understood to
†††††† be the sensitivity specificity of anti-tissue
†††††† transglutaminase antibodies?
†††††††††††††††† DR. MURRAY:† Depending on the study, most
†††††† studies suggest that the sensitivity of tissue
†††††† transglutaminase for celiac disease is in the high
†††††† 90 percent, so the high 90s.
†††††††††††††††† The specificity is probably also in the
†††††† mid- to high 90s, so quite effective when you are
†††††† looking at a population you are suspicious of the
†††††††††††††††† DR. BRILEY:† One more question.
†††††† Margaret Briley.† Do we have any data that shows
†††††† the celiac patient also maybe has been identified
†††††† with a lactose intolerance?† Is there anything that
†††††† combines those two that you would know or does
†††††††††††††††† DR. MURRAY:† The combination is probably
†††††† the damage that is caused by celiac disease, the
†††††† damage to the entrocytes affects your disaccaridase
†††††† including lactase throughout the surface of the
†††††† small bowel, and, hence, you get a secondary
†††††††††††††††† In general, if you think of the genetic
†††††† basis or the ethnic groups that are involved,
†††††† celiac disease tends to hit those of European
†††††† extraction more so.† I know that population will
†††††† tend to retain their lactase activity for longer.
†††††††††††††††† If you look at Subsaharan Africans, for
†††††† example, we don't know actually what the prevalence
†††††† of celiac disease is in Subsaharan Africans, but
†††††† they are individuals who tend to lose their
†††††† Genetically, they are probably separate, but they
†††††† come together because of secondary lactase
†††††† deficiency caused by the damage in celiac disease.
†††††††††††††††† DR. NELSON:†† Thank you, Dr. Murray.† That
†††††† really was a very interesting presentation.† I
†††††† think the last time I studied this was 30 years
†††††††††††††††† CHAIRMAN DURST:† Identify yourself,
†††††††††††††††† DR. NELSON:† Mark Nelson.† I wanted to
†††††† touch base on the couple of slides where you talked
†††††† about how
much gluten is too much and the proposed
†††††† Codex definition for gluten-free foods.
††††††††††††††† †You had a question mark after the
†††††† threshold for damage being 20 to 100 milligrams per
†††††† day, and I guess that is similar to the naturally
†††††† gluten-free foods the Codex proposed.
†††††††††††††††† Then, it goes on to talk about cheating is
†††††† greater than once per month.† Also, is there an
†††††† issue of cumulative exposure, 20 milligrams per
†††††† day, or is the cheating an excursion of whole wheat
†††††† crackers, for example?
†††††††††††††††† DR. MURRAY:† Well, first of all, the
†††††† comment on cheating that is what the patients tell
†††††† me, those patients who will admit to gross
†††††† cheating, that is, eating a piece of bread or a
†††††† cookie or cake, which is what I regard as an
†††††† obvious source of gluten.
†††††††††††††††† However, that may reflect some other
†††††† background, but a lack of detail of care, for
†††††† example, attention to detail in the rest of their
†††††† diet, maybe what they are not telling us.† That
†††††† only applies to what they have told me.
The issue of actual threshold, I have a
†††††† question mark after that because we will hear a lot
†††††† more detail, science, about threshold testing for
†††††† thresholds of gluten contamination.
†††††††††††††††† The intermittent contamination, once a
†††††† month obvious contamination.† Something that is, to
†††††† some degree, under the patient's control with
†††††† appropriate education and exposure to information
†††††† then essentially it is under their control.
†††††††††††††††† It is the low-level contamination on a
†††††† regular basis from sources they are not aware of,
†††††† and those are the patients that I see that make up
††† †††the majority of the patients I see who have
†††††† difficulty.† They are coming to me because they are
†††††† trying to be gluten-free, but they are having
†††††† contamination of their diet on a daily basis,
†††††† probably a relatively small amount.† We will hear a
†††††† lot more about the threshold, the actual testing of
†††††† the threshold using that type of low-level daily
†††††††††††††††† DR. MALEKI:† Soheila Maleki.† Is there an
†††††† adult onset or spontaneous development of celiac
†††††† disease, or
does this have to come with a genetic
†††††† component and hereditary?
†††††††††††††††† DR. MURRAY:† It probably only occurs in
†††††† people who have that HLA or genetic type.† You have
†††††† to have it.† However, that is 30-plus percent of
†††††† the Caucasian population.
†††††††††††††††† Can it start first in adulthood?† We have
†††††† very little data on that.† The only data is the
††† †††stuff I have mentioned, looking at children and
†††††† showing about 1 percent by the age of seven or
†††††† eight, positive by the age of seven or eight, the
†††††† same prevalence if you look at adulthood.
†††††††††††††††† There are a few cases of what we call
†††††† "latent celiac disease," individuals who have got
†††††† antibodies with apparently normal small intestinal
†††††† biopsies as adults, then go on over a space of
†††††† years to develop full-blown celiac disease within
†††††† years of that initial identification of a positive
†††††† serology.† Those are very rare cases that have been
†††††††††††††††† Of course, if you find somebody who
†††††† suspects they have got a problem, they ought to
their diet anyway, and that changes
†††††† everything.† There is very little data, I think, to
†††††† be sure of whether it first occurs, starts, in
†††††††††††††††† If you look at the age of diagnosis, your
†††††† eighth or ninth decade can be the first time that
†††††† you are diagnosed with celiac disease.† A lot of
†††††† those patients have suspicious symptoms going back
†††††† many years.
†††††††††††††††† DR. BRITTAIN:† Erica Brittain.† Can you
†††††† quantify the level of damage?† Is that only
†††††† possible with the biopsy, and is that very
†††††††††††††††† DR. MURRAY:† You can -- well, if you take
†††††† biopsies, you can quantify the degree of injury.† I
†††††† showed that slide which shows a spectrum of injury.
†††††† It tends to be variable, even within the same
†††††† individual.† It started in the first part of the
†††††† small intestine and extends a variable distance
†††††† down the small intestine.
†††††††††††††††† There has really only been one study,
†††††† which was done in the early 1960s, of taking
biopsies down the intestine -- a handful
†††††† of courageous volunteers.
†††††††††††††††† It is not clear that there is a
†††††† correlation between the extent of injury and the
†††††† severity of symptoms.† In fact, we don't know how
†††††† to predict the occurrence of symptoms in patients
†††††† with celiac disease, so that is a "black box."
†††††††††††††††† DR. BRITTAIN:† You are saying there is
†††††† really no simple way to quantify the extent of
†††††† damage?† There is nothing that would correlate with
†††††† these multiple biopsies?
†††††††††††††††† DR. MURRAY:† Some people have suggested
†††††† that the level of the antibodies, the tighter the
†††††† antibodies might correlate:† The higher, the
†††††† tighter, maybe the more severe the injury to the
†††††† intestinal biopsies.
†††††††††††††††† When we take a biopsy of the intestine, we
†††††† are sampling a tiny fraction of a percentage of
†††††† 1 percent, a fraction of 1 percent, of the
†††††† intestinal lining.† We have tried to look using
†††††† other imaging techniques to assess the extent of
†††††† injury.† Using some of those techniques seems to be
variable between individuals, and it doesn't
†††††† seem to predict their symptoms.
†††††††††††††††† Really right now it is a yes or no issue:
†††††† yes, they have celiac disease; or, no, they do not.
†††††† It is very hard to measure the severity of the
†††††††††††††††† We can look at the severity of
†††††† consequences: have they developed osteoporosis,
†††††† what their bone density is, have they lost a lot of
†††††† weight, whether they have severe malabsorption
†††††† based on fat malabsorption in their stool.† We have
†††††† got other measures to look at the consequences or
†††††† impact of the disease, those we can assess.
†††††††††††††††† DR. BRITTAIN:† Do you think that it would
†††††† correlate with the intestinal damage?† Not
†††††††††††††††† DR. MURRAY:† We have tried.† I would say
†††††† that the data is not very good on that.† People
†††††† with very mild injury may be more likely to be
†††††† asymptomatic, but the data is not sound.
†††††††††††††††† CHAIRMAN DURST:† Suzanne.
†††††††††††††††† DR. MALEKI:† Suzanne Teuber.† I had a
about the neurologic presentations.† I
†††††† have read some on screening of pediatric
†††††† populations, but with adults how often does it
†††††† present as dementia without it being diagnosed as a
†††††† GI problem?† Is this something we should be adding
†††††† to dementia screening?
†††††††††††††††† DR. MURRAY:† It is probably relatively
†††††† rare.† In fact, I think there has only been one
†††† ††good study.† Maybe Dr. Collin, who is here as a
†††††† speaker later, has done a study and has looked at
†††††† and reported on that.
†††††††††††††††† We occasionally see cognitive decline at
†††††† the time of diagnosis, but there is really no good
†††††† epidemiologic study to address that.† Some of the
†††††† other presentations, peripheral neuropathy, for
†††††† example, or ataxia, there is more data on it.† Many
†††††† neurologists are beginning to include celiac
†††††† disease as part of their differential diagnosis for
†††††† those syndromes.† Good epidemiology data is
†††††† relatively small, very little data.
†††††††††††††††† CHAIRMAN DURST:† Ciaran.
†††††††††††††††† DR. KELLY:† Ciaran Kelly.† This is
more clarification than a question.† Dr.
†††††† Murray is quite correct that there isn't a measure
†††††† of either severity of intestine abnormality or even
†††††† height of antibody levels that reliably reflects
†††††† the degree of injury or correlates closely with
†††††††††††††††† However, with treatment one can use a
†††††† decline in antibody levels as a crude indicator of
†††††† at least reduced exposure to gross amounts of
†††††† gluten.† It is not a very sensitive indicator, but
†††††† it is useful.† Of course, with repeat biopsy, if
†††††† the histology has revered to normal, that of course
†††††† can be used.† However, the less invasive test of
†††††† following antibody levels is used clinically to
†††††† follow response.
†††††††††††††††† DR. MURRAY:† Quite right.† I think you
†††††† will agree, Joe.
†††††††††††††††† DR. KELLY:† If the antibody levels aren't
†††††† dropping, that is used as an indication that the
†††††† patient is successfully on a gluten-free diet.
†††††††††††††††† DR. BRILEY:† Margaret Briley.† Can you
†††††† give us any idea of any behavior data that you may
received from your patients regarding their
†††††† willingness to try foods that are not gluten-free
†††††††††††††††† DR. MURRAY:† Oh, well, there are many
†††††† different attitudes among patients with regard to
†††††† what they want to eat or what they are afraid to
†††††††††††††††† I advise my patients to be prudent, that
†††††† they try to select things based on identification
†††††† of ingredients, source ingredients, not containing
†††††† things contained from gluten, the use of substitute
†††††† grains that are gluten-free.
†††††††††††††††† Many patients are quite willing to do that
†††††† on their own.† Many of them use support group
†††††† information where maybe a group has cooperatively
†††††† contacted manufacturers who in good faith provide
†††††† information on their source ingredients.
†††††††††††††††† There are some patients who are entirely
†††††† paranoid about it, and want to obtain a kit to test
†††††† the food.† I don't know that we've got a very
†††††† effective kit yet for testing food for gluten
†††††† contamination.† There are many different attitudes.
Fear is a major concern among my patients.
†††††† I mean, fear of even the slightest potential, not
†††††† even actual but potential contamination.† This can
†††††† verge on, "Do we avoid taking prescription
†††††† medications for things like hypertension?"
†††††† resulting in life-threatening changes to their
†††††† medication regimens because of fear of
†††††††††††††††† I would say fear is a major part or a
†††††† major influence on the quality of life.† We will
†††††† hear more I think shortly on the impact of a
†††††† gluten-free diet on patients' lifestyles a little
†††††† later.† Certainly that does affect a substantial
†††††† portion of my patients.
†††††††††††††††† Patients go through a substantial grief
†††††† reaction and feel socially isolated because of
†††††† their difficulty of interacting with society,
†††††† because so much of our society activities or social
†††††† activities revolve around food.† There is that
†††††† safety sense of insecurity, which I think pervades
†††††† or affects many patients with celiac disease.
†††††††††††††††† DR. BRILEY:† Thank you.
CHAIRMAN DURST:† Soheila.
†††††††††††††††† DR. MALEKI:† Well, I just want to know if
†††††† there are any coordinated studies for a
†††††† determination of thresholds?† I know you mentioned
†††††† the level of PPMs.† Do you know of any studies?
†††††††††††††††† DR. MURRAY:† There are and you will hear
†††††† about them.† There are both retrospective and
†††††† prospective studies, and you will be hearing some
†††††† data on those later this morning.
†††††††††††††††† CHAIRMAN DURST:† I have one question --
†††††† Dick Durst -- on the biopsy and histological
†††††† studies to see the morphology, morphological
†††††† changes, you showed from the shag rug.† I am just
†††††† curious whether just one of these cameras you can
†††††† swallow would be able to detect those kind of
†††††† changes without having to go through a biopsy?
†††††††††††† ††††DR. MURRAY:† Yes, you can detect them.
†††††† Nobody would suggest that it would replace the need
†††††† for biopsies to make the diagnosis.† There is
†††††† really relatively little published data on it.
†††††† There has been a paper suggesting that you can see
†††††† those changes.† With a magnified view, you can see
†††††† with a
†††††††††††††††† Yes, I think you can identify those
†††††† changes in a lot of individuals with celiac
†††††† disease, maybe all of them.† Although, I really
†††††† can't comment more on that, because it hasn't
†††††† really been studied in any great detail.
††††††††††† †††††CHAIRMAN DURST:† Erica.
†††††††††††††††† DR. BRITTAIN:† Erica Brittain.† Do you
†††††† have any insight about the cumulative effect of
†††††† decades of low levels, very, very low levels of
†††††† gluten exposure?† Certainly, we are going to have
†††††† to think about what chronic exposure could do when
††††† †we talk about the thresholds.† Can you provide any
†††††† insight into that?
†††††††††††††††† DR. MURRAY:† Probably the best clinical
†††††† insight I can give are individuals who I see who
†††††† were diagnosed 20 years ago and have not come back
† †††††to medical attention in 20 years.† I see those
†††††† patients maybe every week.
†††††††††††††††† I would see somebody who is diagnosed 20
†††††† years ago, and they got instruction at that time
†††††† that allowed them to eat things like barley malt or
†††††† that people
weren't really instructed about some of
†††††† those rice or corn cereals that may have contained
†††††† malt, for example.
†††††††††††††††† Those patients come back with anemia,
†††††† chronic GI complaints, maybe not as severe as they
†††††† had initially, but they certainly have accumulated
†††††† some health morbidity over those 20 years.† Some of
†††††† them will come back with frank lymphomas and will
†††††† end up with a mortal complication of their celiac
†††††††††††††††† Yes, at least my clinical observation is
†††††† that I frequently see individuals with problems
†††††† that we get rid of, once they now move to a much
†††† ††more strict gluten-free diet, by eliminating those
†††††† things -- largely, because in 20 years they didn't
†††††† go back and get more education and realize that you
†††††† had to exclude those minor ingredients.† That is
†††††† one way of looking at the effects of decades'
†††††† accumulation of low-level contamination.
†††††††††††††††† CHAIRMAN DURST:† Dick Durst again.† On
†††††† your slide that showed the various causes, the
†††††† different grains, and so on, I believe you
oats was not one of the causes.† Could
†††††† you expand on that?
†††††††††††††††† DR. MURRAY:† We will hear a little more, I
†††††† think, from Dr. Collin on that issue.† While oats
†††††† had been thought to be one of the offending grains
†††††† in things done in the fifties and sixties, it turns
†††††† out from recent very well-done studies that it
†††††† doesn't appear to impair the healing of the
†††††† intestine in newly diagnosed celiac disease.† It
†††††† doesn't seem to result in a significant worsening
†††††† of production of damage in patients who are already
†††††† diagnosed with celiac disease.
†††††††††††††††† For the vast majority of celiacs, it is
†††††† probably safe in its native, pure form.† However,
†††††† there are some sequences within oats that can
†††††† produce an immune response, at least in vitro, in
†††††† lymphocytes derived from a few celiacs.
†††††††††††††††† It is not an absolute.† There may be some
†††††† individuals with celiac disease that can respond to
†††††† oats, both in the laboratory test and possibly also
†††††† clinically there are a few.
†††††††††††††††† There are probably a relatively small
†††††† minority of
celiacs in which that occurs.† A bigger
†††††† concern is the issue of contamination of oats with
†††††† other grains that are well recognized to cause
†††††††††††††††† CHAIRMAN DURST:† Marc.
†††††††††††††††† DR. SILVERSTEIN:† Marc Silverstein.† I
†††††† would like to inquire about the potential
†††††† subsequent lifelong increased risk of GI cancers.
†††††† I presume that the risk is predominantly small
†††††† bowel, but I wonder if there is any increased risk
†††††† of colorectal cancer?
†††††††††††††††† Then, what are your thoughts about whether
†††††† there is sufficient risk that patients with celiac
†††††† disease should be in some sort of surveillance
†††††† program for early detection of GI cancer?
†††††††††††††††† DR. MURRAY:† Clarifying the risk of
†††††† cancers, it is particularly visceral cancer but
†††††† also includes: esophageal cancer, non-Hodgkin's
†††††† lymphoma of any site not just the intestine, and
†††††† probably also B-cell lymphomas, as well as the
†††††† T-cell lymphomas, small-bowel carcinoma.
†††††††††††††††† There is a greatly increased relative risk
small-bowel carcinoma.† Of course
†††††† carcinomas is a very rare disease to begin with, so
†††††† the lifetime risk of dying of a small-bowel cancer,
†††††† even in a celiacs, is still relatively small.† The
†††††† data on colon cancer is mixed.† There is some that
†††††† suggests there is an association; and some, that
†††††† does not.
†††††††††††††††† When you look at other causes of
†††††† mortality, even non-cancer causes of mortality such
†††††† as infections, neurologic disorders and chronic
†††††† lung infections, there are other excesses of
†††††† mortality that occur in patients with celiac
†††††††††††††††† There are some reductions in cancer
†††††† mortality.† It appears, at least there is a
†††††† suggestion, that breast cancer may be less common
†††††† in celiac disease than non-celiac disease.† There
†††††† were a couple of suggestions that lung cancer might
†††††† be less common in celiac disease than in non-celiac
†††††††††††††††† Now, whether there is some competing issue
†††††† like smoking may be less common in celiac disease
non-celiac disease, so there may be some other
†††††† competing issues that are involved.† Body size may
†††††† make a difference.† It may be another confounding
†††††† issue that confounds or is a competing risk for
†††††††††††††††† While small-bowel cancers and lymphomas
†††††† are the two that have the greatest relative risk,
†††††† it is a small, absolute risk because of the
†††††† relative rarity of those cancers.
†††††††††††††††† CHAIRMAN DURST:† Do we have any further
†††††† questions for Dr. Murray?
†††††††††††††††† (No verbal response.)
††††† †††††††††††CHAIRMAN DURST:† Thank you very much.
†††††††††††††††† Our next speaker is Cynthia Kupper, who is
†††††† the executive director of the Gluten Intolerance
†††††† Group of North America who will present on patient
†††††† perspectives on celiac disease.
††††††††††††††††† PATIENT PERSPECTIVES ON CELIAC DISEASE
†††††††††††††††† MS. KUPPER:† Good morning.† I am a
†††††† dietician, not a doctor.† I appreciate the honorary
†††††† doctor status.
†††††††††††††††† My job here today is to give a face for a
†††††† person with
celiac disease.† I have been tasked
†††††† with letting you know who they are, letting you
†††††† know how they get their information and education,
††††† †and then also providing you with some information
†††††† about labeling that they have.
†††††††††††††††† MS. KUPPER:† First of all, living with
†††††† celiac disease is very difficult.† It is a chronic,
†††††† lifelong condition, as you have heard, and people
†††††† find this to impact greatly their quality of life.
†††††††††††††††† Forty-four percent of the patients in a
†††††† Canadian study say that the diet is very difficult
†††††† to follow.† In fact, there are some studies that
†††††† suggest that the compliance with the diet can be as
†††††† low as 50 percent in teenagers but probably ranges
†††††† around 70 percent compliance.
†††††††††††††††† Eighty-four percent of these patients in
†††††† Canada suggested they have a difficult time
†††††† determining what is gluten-free and what is not.
†††††† They don't travel, and they don't eat out.† It
†††††† impacts their family life and their career.
†††††††††††††††† If you have celiac disease and are an
technician, oftentimes you change careers
†††††† because sometimes the X-ray slides are dusted with
†††††† flour.† Chronic exposure could impact your quality
†††††† of life.
†††††††††††††††† MS. KUPPER:† I did a study online of 620
†††††† patients a few months ago.† In response to that
†††††† study, 75 percent of them said that they can tell
†††††† the difference between a gluten reaction and other
† †††††intolerance or a food allergy.
†††††††††††††††† When they discussed their reaction
†††††† symptoms, they ranged from anaphylaxis, which is
†††††† not a gluten reaction for celiac disease, to
†††††† delayed reactions which could impact any aspect of
†††††† their GI and other health systems, body systems.
†††††††††††††††† The average time to reaction was somewhere
†††††† between four to eight hours, but some of them
†††††† complained of immediate, almost allergic type
†††††† responses, and many of them said that their
†††††† responses or the symptoms that they had would last
†††††† for several days.
†††††††††††††††† Keep in mind, there is no medication we
†††††† can give
them to make this go away, so they just
†††††† have to let it work its course.† This is really
†††††† disturbing to me.
†††††††††††††††† MS. KUPPER:† As a dietitian, patients do
†††††† not rely on medical communities and professionals
†††††† for their information.† They rely primarily on
†††††† support groups.
†††††††††††††††† Actually, the Internet should probably be
†††††† the first one, because they are Internet savvy.
†††††† They have been out there and they have gotten all
†††††† kinds of information before they ever see a
†††††† dietitian.† Not only do they get information from
†††††† the Internet and the support groups, but there are
†††††† list serves and chat groups that they belong to.
†††††††††††††††† These can be very useful tools for a
†††††† person with celiac disease.† However, they also
†††††† provide some very frightening and unreliable
†††††† information that the patients will hold onto as if
†††††† it were gospel.† Then, they work with self-help
†††††† books as well.
†††††††††††††††† Unfortunately, doctors, and especially
are seen as unreliable.† It is sad for
†††††† me to say that as a dietitian my profession doesn't
†††††† get this disease.† They also treat it like it is a
†††††† rare thing, and they don't know anything about it.
†††††† In the United States, I can tell you that there is
†††††† probably a handful of dietitians who would be
†††††† considered experts in celiac disease.
†††††††††††††††† Doctors don't get much more respect,
†††††† primarily because it has taken so long for the
†††††† patient to get a diagnosis that the patient has
†††††† lost faith.
†††††††††††††††† Then, they will go to research facilities
†††††† like the University of Maryland, Chicago, and
†††††† New York, or the Mayo Clinic.† Lastly, they will go
†††††† to medical Web sites.† The bulk of our information
†††††† is coming from potentially unreliable and
†††††† non-research-based sites.
†††††††††††††††† MS. KUPPER:† The consumers perceive that
†††††† gluten exposure levels -- the question was asked to
†††††† me, "What do consumers believe about gluten
†††††† exposure?† Are they concerned about the health
risks?"† The answer is yes
†††††††††††††††† On the study that I did, it depended upon
†††††† their confidence of the labeling, and it depended
†††††† on whether they accepted testimony or accepted
†††††† research.† There is a group of celiacs, as
†††††† Dr. Murray suggested, who really don't want to
†††††† listen to what research suggests.
†††††††††††††††† As you move forward, with not only
†††††† establishing how you are going to determine the
†††††† threshold but what that threshold will be, you will
†††††† have a fight in the celiac community for a lack of
†††††† education and understanding of research.
†††††††††††††††† Consumers oftentimes also have an
†††††† inability to correctly interpret research findings.
†††††† These are people who have just enough medical
†††††† knowledge to be dangerous, so they don't have a
†††††† full understanding of the terminology they are
†††††† talking about.
†††††††††††††††† There is this constant perpetuation of
†††††† misinformation.† I don't know how many times when
†††††† we try to bury something that is inaccurate it gets
†††††† dug up.
†††††††††††††††† MS. KUPPER:† There are varying levels of
†††††† gluten sensitivity, as you heard, too.† There is
†††††† the perception that gluten is poison.† Not unlike
†††††† the allergy people that we heard from yesterday,
†††††† this is a huge issue to the celiac consumer.
†††††††††††††††† They believe most of the time that when
†††††† their gut hurts it is from gluten not from
†††††† something else.† Consequently, we are trying to
†††††† help the patient understand that not everything
†††††† that makes their gut hurt is gluten.
†††††††††††††††† As Dr. Murray said, there is a huge fear
†††††† reaction.† If I had to put a psychological label to
†††††† a group or at least a portion of the celiac
††† †††community, they are filled with fear and a little
†††††† bit paranoid about what they can and can't do.
†††††††††††††††† How do we define "gluten-free" in the
†††††† U.S.?† This is a really interesting question.† Of
†††††† the consumers, only 19 percent realize that there
†††††† is no definition right now for gluten-free in the
†††††† U.S.† Many of them define that the true definition
†††††† is zero.† This is a problem -- a lot don't know.
†††††††††††††††† MS. KUPPER:† When I ask the question, "Do
†††††† you trust gluten-free labeling?"† It was
†††††† interesting, too, because most of the people say
†††††† they do trust it.† However, when you ask them if
†††††† they ever had a reaction to a product labeled
†††††† gluten-free, you can see that up to 50 percent
†††††† suggested that they might have had a reaction to a
†††††† gluten-free product.
†††††††††††††††† When I talk to manufacturers that
†††††† manufacture only gluten-free products and ask them,
†††††† "Do you test, and what do you test to," many of
†††††† them are using older testing methods not the newer
†††††† testing methods, the monoclonal tests that we
†††††† talked about yesterday.
†††††††††††††††† Some of them tested 200 parts per million,
†††††† some of them tested 20 parts per million, some of
†††††† them tested no detectible.† For the gluten-free
†††††† consumer today, the label "gluten-free" really has
†††††† no meaning.
†††††††††††††††† MS. KUPPER:† Again, the gluten-free
†††††† consumer is
compulsive about their medical needs.†
†††††† This is their only treatment.† It is often referred
†††††† to as our drug of choice.† There is nothing else we
†††††† can do, except to follow a strict gluten-free diet.
†††††††††††††††† They have very limited trust in the
†††††† manufacturing industry.† They believe that labels
†††††† that say "may contain" and different things like
†††††† that need to be distrusted.† When they call the
†††††† manufacturers, they are not quite sure that they
†††††† are getting the right answer all the time.
†††††††††††††††† Also, they have a limited understanding of
†††††† what good manufacturing practices really mean, so
†††††† they are always questioning what the manufacturer
†††††† will say.† Yet, at the same time they want
†††††† accountability and they want reliability.
†††††††††††††††† They may translate information to the
†††††† extreme.† Let me give you an example.† A few months
†††††† ago on one of the list serves, someone put out a
†††††† message about bottled water being gluten-free.
†††††††††††††††† That got taken in a week's time to the
†††††† point where consumers were calling asking why water
†††††† had gluten in it, and how dare the food industry do
†††††† that to
them.† The reality is it never did.
†††† ††††††††††††A company, out of the graciousness of
†††††† their heart, put it on a list of gluten-free
†††††† products, and from that the consumer decided that
†††††† every other bottled water had gluten in it.† This
†††††† is the extreme that the consumer can go to.† Again,
†††††† they don't find descriptive labeling helpful at
†††††††††††††††† The changes that can occur in ingredients
†††††† in manufacturing processes make it difficult for
†††††† this consumer group to know what they can have.
†††††† The term "modified food starch" usually means
†††††† cornstarch, modified cornstarch, in this country.
†††††††††††††††† However, if the manufacturer determines
†††††† that wheat starch is cheaper in the fall and they
†††††† switch and the consumer has determined that this
†††††† product is gluten-free, now they are in trouble if
†††††† they don't recheck.
†††††††††††††††† When you talk to the food industry, you
†††††† will find that their calls have dramatically
†††††† increased over the last 2 to 5 years of consumers
†††††† calling in, and 90 percent of the questions do not
†††††† have to do
with other allergens but have to do with
†††††††††††††††† MS. KUPPER:† When the consumer asks the
†††††† question about gluten, the problem is that they are
†††††† asking the wrong question.† The consumers believe
†††††† that if they don't have effective labeling how can
††††† †anybody possibly know that they are going to be
†††††† able to be healthy and protect themselves.
†††††††††††††††† They want to know that if you call a
†††††† company they are really giving you the right
†††††† answer, and they are just never confident about
†††††† that.† Oftentimes, when the company answers too
†††††† quickly, they get suspicious.
†††††††††††††††† Oh, I've had that experience.† I will call
†††††† on a product and I'll say, "I need to know the
†††††† source of the modified food starch."
†††††††††††††††† "Oh, you're talking about gluten?"
†††††††††††††††† "Yes.† Tell me the source of your modified
†††††† food starch.† Let me make that decision about
†††††† whether I'm talking about gluten."† That makes a
†††††† consumer suspicious.
Finally, you know, if a person eats a
†††††† gluten-free food and they get sick, whether it is
†††††† related to gluten ingestion or not, they have
†††††† determined that they can't trust that company any
†††††††††††††††† Again, these list serves and chat groups,
†††††† I have seen them take small companies out of
†††††† business because of the spreading of rumors --
†††††† which are probably unfounded.
†††††††††††††††† MS. KUPPER:† In closing thoughts, I really
†††††† encourage that through this entire process related
†††††† to labeling thresholds, that we be talking a common
†††††††††††††††† Let me use the example of threshold.
†††††† Yesterday, as I listened to Anne Munoz talk about
†††††† thresholds for allergens, I realized that we have
†††††† three different definitions of thresholds -- or
†††††† tolerance, excuse me.† I want to use the word
†††††††††††††††† The consumer says, "Tolerance is zero."
†††††† What that means is they think there should be zero
†††††† gluten in
†††††††††††† ††††The medical community says "zero
†††††† tolerance."† For them that means, you should be on
†††††† a strict diet, and you should never cheat.
†††††††††††††††† The manufacturing industry wants to know
†††††† where that is.† Is it 20?† Is it 200?† They know it
†††††† is not zero.
†††††††††††††††† We are not talking the same language.† The
†††††† consumer needs to know that the manufacturer and
†††††† the industry or the legal ramifications around any
†††††† labeling are all using common terminology in a
†††††† language they can understand.
†††††††††††††††† Education is a huge component.† As much as
†††††† I am a supporter of this regulation and this law,
†††††† one of the things that is going to happen, as you
†††††† heard yesterday in discussions about soy lecithin
†††††† and other ingredients, it is going to become a bag
†††††† of worms.† For the consumer, it is going to be very
†††††† confusing, and we need to have an education
†††††† component as part of the new labeling laws.
††††††† †††††††††I encourage you, too, although you heard
†††††† it yesterday and you will probably hear it today,
†††††† too, we
know that there is no testing kit available
†††††† that tests to zero.† We know, as you will probably
†††††† hear later, that it is probably an impracticality
†††††† or unnecessary to even go there.
†††††††††††††††† I implore that when you set a threshold
†††††† method and testing methods, when you set the
††† †††threshold level, that it be reasonable and
†††††† something that meets the health needs of the
†††††† consumer but also allows the industry to meet the
†††††††††††††††† MS. KUPPER:† As they found out in
†††† ††Australia, when you set zero as the tolerance level
†††††† and as the magic number for food manufacturers, a
†††††† lot of gluten-free products that patients used no
†††††† longer can be labeled gluten-free.† Now the
†††††† consumer is once again confused and outraged.
†††††††††††††††† CHAIRMAN DURST:† Thank you very much.
†††††††††††††††† Do we have any questions for our speaker?
†††††††††††††††† Yes, Jeff?
†††††††††††††††† DR. BARACH:† Hi.† Thank you.† Jeff Barach
†††††† with Food Products Association.† If I interpret
†††††† what you
said correctly, you were talking about the
†††††† consumer really doesn't find descriptive labeling
†††††† very helpful in the case of gluten-free.
†††††††††††††††† I assume then the consumer would go to the
†††††† ingredient list or the 800 numbers or their
†††††† internal chat groups to find out whether the
†††††† product really is gluten-free or not.† Am I
†††††† interpreting that right?† Your constituency does
†††††† not want gluten-free labeling?
†††††††††††††††† MS. KUPPER:† I would say that is probably
†††††† right, that is the message I got from the survey.
†††††† In fact, they found that labels that say "may
†††††† contain" or "processed in a plant with" really is
†††††† frightening to them.† They will look at a product
†††††† like that, and they will simply avoid it.
†††††††††††††††† They do go to chat rooms and there are
†††††† lists of gluten-free products.† However, when you
†††††† look at those lists and you ask how they were
†††††† developed, there are no standards for developing
†††††† those lists.
†††††††††††††††† DR. HEIMBURGER:† Doug Heimburger, a follow
†††††† up to that.† That is not the same, is it, as saying
"gluten-free"?† Do they
not want a label except it
†††††† is gluten-free with a consistent and clear
†††††† definition of that?
†††††††††††††††† MS. KUPPER:† They do want a label that
†††††† says gluten-free with a clear and consistent
†††††††††††††††† DR. HEIMBURGER:† Yes.
†††††††††††††††† MS. KUPPER:† I believe that gluten-free is
†††††† not is not going to mean zero; it can't mean zero.
†††††††††† ††††††CHAIRMAN DURST:† Any further questions or
†††††††††††††††† (No verbal response.)
†††††††††††††††† CHAIRMAN DURST:† Thank you very much.
†††††††††††††††† CHAIRMAN DURST:† Our next speaker is
†††††† Dr. Donald Kasarda, who is a consultant and retired
†††††† senior scientist from the Agricultural Research
†††††† Service of the USDA.† He will make a presentation
†††††† on grains.
†††††††††††††††† DR. KASARDA:† Good morning everyone.† I am
†††††† a research chemist retired from the U.S. Department
†††††† of Agriculture, although I still maintain a
relationship with my old lab in Albany, California,
†††††† as a collaborator.
†††††††††††††††† Now, Dr. Murray covered a lot of the
†††††† things I am going to talk about.† Maybe I will be
†††††† able to add a little bit more detail to some of
†††††† them, but he did an excellent job of talking about
†††††† some of the grain topics.
†††††††††††††††† DR. KASARDA:† Immunology textbooks often
†††††† classify hypersensitivities into these four types.
†††††† Celiac disease is a delayed type hypersensitivity
†††††† that involves T-cells in the primary mechanism.† It
†††††† falls into Type IV.† Allergy is Type I and is
†††††† mediated by IgE antibodies.
†††††††††††††††† Now, in the case of celiac disease, it is
†††††† often suggested that there is a Th1 mechanism
†††††† involved in which T-cells are presented with
†††††† gliadin peptides, and, ultimately produce
†††††† cytokines, inflammatory cytokines such as
†††††† interferon gammas as an example.
†††††††††††††††† Now, in the case of allergy, however, the
†††††† same molecules that can induce the symptoms of
disease are also capable of producing
†††††† allergies.† We do have a certain amount of
†††††† confusion sometimes between immediate
††††† †hypersensitivities and the delayed-type, celiac
†††††††††††††††† DR. KASARDA:† Now, this is the same
†††††† diagram that Dr. Murray showed.† I want to talk
†††††† about primarily the endosperm, which is this white
†††††† part here (indicating) in the cutaway diagram.
†††††††††††††††† The starchy endosperm is made up of about
†††††† 75 percent starch, but it also contains about 7 to
†††††† 17 percent protein, depending on the use of the
†††††† wheat.† Most of this protein, about 75 percent of
†††††† it, is gluten protein.
†††††††††††††††† The proteins are storage proteins.† They
†††††† are used by the developing plant that comes from
†††††† the germ here.† The germ is separated from the
†††††† outer layers and the endosperm during the milling
†††††† process after crushing and sieving.
†††††††††††††††† The storage proteins are broken down upon
†††††† germination of the seed to produce a new plant.
resulting amino acids and nitrogen are used in
†††††† the synthesis of new molecules needed by the
†††††† developing plant.† Now, as I mentioned, about 75
†††††† percent of the storage protein is, in fact, gluten
†††††††††††††††† DR. KASARDA:† This is a picture of flour
†††††† particles, a scanning electron micrograph.† These
†††††† round, spherical structures are starch granules.
†††††† These (indicating) are A type, there are some
†††††† B types which are small here.† The surrounding
†††††† rough-edged material is the gluten protein or
†††††† storage protein.
†††††††††††††††† DR. KASARDA:† If you mix together flour
†††††† and water, as most of you have had the experience,
†††††† you can form a cohesive elastic dough.† If you need
†††††† a dough under water, say, in a large container of
†††††† water or under a stream of water, you can wash out
†††††† the starch granules; they pop right out of the
†††††† matrix.† You are left with a cohesive, elastic mask
†††††† consisting mainly of the storage or gluten
†††††††††††††††† DR. KASARDA:† Now, this is the traditional
†††††† cereal chemist definition of gluten.† You cannot
†††††† carry out this process with rye and barley.
†††††† Therefore, to the traditional cereal chemist, there
†††††† is no gluten in rye and barley.† However, the
†††††† celiac disease community has adopted the term
†††††† "gluten" for any protein that is toxic or harmful
†††††† to a celiac patient.
†††††††††††††††† This terminology problem sometimes is
†††††† confusing when patients go to a company where they
†††††† might be dealing with a traditional cereal chemist,
†††††† and there is a certain amount of confusion as to
†††††† what is gluten.† As I said, this is the traditional
†††††† definition, but it has been expanded to include
†††††† other grains that are harmful to celiac patients.
†††††††††††††††† Now, from time to time, you will hear
†††††† about these fractions of gluten.† Going way back,
†††††† at least over a hundred years, it has been
†††††† traditional to divide gluten into two, roughly,
†††††† equal fractions based on their solubility.† This is
†††††† not an
exact separation.† No solubility
†††††† ever perfect.
†††††††††††††††† Traditionally, it was alcohol-water
†††††† solution and sometimes we used detergent solutions.
†††††† We divide it up into the soluble fraction, which we
†††††† call "gliadin."
†††††††††††††††† This is made up of monomeric proteins of
†††††† the prolamin class.† The prolamin terminology comes
†††††† from Osbourne back around 1900.† It is derived from
†††††† the fact that there are two major amino acids found
†††††† in the composition of these proteins.† Proline and
†††††† glutamine, hence, prolamin.
†††††††††††††††† By structure, we have three types: the
†††††† alpha type, gamma type, or omega types.† Sometimes
†††††† people speak of the alpha/beta.† I will talk about
†††††† that in a little as we go along.
†††††††††††††††† Now, the insoluble fraction is called
††††† †"glutenin" by the cereal chemists.† In rye and
†††††† barley, there is an equivalent fraction that we
†††† ††called just generically "glutelin."
†††††††††††††††† Now, this polymeric fraction consists of
†††††† prolamin subunits.† Again, large amounts of proline
glutamine in the composition of the proteins.†
†††††† These subunits are linked together by disulfide
†††††† bonds into a higher level of polymer.
†††††††††††† ††††Of course, a protein is a polymer in
†††††† itself.† It is divided into two main types the
†††††† low-molecular weight and the high-molecular weight
†††††† glutenin subunits.
†††††††††††††††† DR. KASARDA:† This just is a table showing
†††††† the percentages in the various types of proteins.
†††††† For example, you have the sum of glutamine and
†††††† proline ranging from about 40 percent up to about
†††††† 80 percent in some of the omega gliadins.
†††††††††††††††† This is pretty unusual to have such a high
†††††† percentage of glutamine and proline.† This is key
†††††† to the toxicity, because the toxic sequences
†††††† involve glutamine and proline and usually an
†††††† aromatic as well, either tyrosine or phenylalanine.
†††††††††††††††† DR. KASARDA:† Now, the terminologies that
†††††† we use really go back to early electrophoretic
†††††† studies in the late sixties and early seventies.
†††††† Again, if
we follow this diagram here, this is an
†††††† acid gel in which the proteins are separated by an
†††††† electric field in a polyacrylamide gel.
†††††††††††††††† The terminology actually came from a sort
†††††† of free-boundary electrophoresis that was carried
†††††† out at our Northern Regional Research Center back
†††††† in the sixties.† When they developed the
†††††† polyacrylamide gel electrophoresis, it was found
†††††† that the fractions fit with the mobility in the
†††††† electrophoretic gel.
†††††††††††††††† You have the alpha, fastest moving; beta;
†††††† gamma; and omega.† Structurally, the alphas and
†††††† betas are pretty similar.† Some people will talk
†††††† about alpha/beta types.† I just lump them together
†††††† as alpha types.
†††††††††††††††† Now, the alpha type and gamma type are
†††††† about the same size.† If you carry out SDS page or
†††††† polyacrylamide gel electrophoresis in detergent,
†††††† sodium dodecyl sulfate, which is a very good
†††††† dissociating agent for proteins.
†††††††††††††††† Reduced or unreduced the gliadins give a
†††††† pattern somewhat similar to this.† It is not quite
†††††† as good at
resolving alpha, beta and gammas as you
†††††† find in the acid gels where aluminum lactate was
†††††† one of the favorite buffers.
†††††††††††††††† If we go over to the glutenin fraction,
†††††† and these are the subunits linked together by
††††† †disulfide bonds, if you try to take a purified
†††††† glutenin fraction and run it into an acid gel or
†††††† into a detergent gel, mostly you've just got a
†††††† little bit of streaking around the origin because
†††††† the polymers are too large to migrate into the gel.
†††††††††††††††† DR. KASARDA:† Upon reduction, however, you
†††††† begin to see this type of pattern here in which
†††††† there is a group of high-molecular-weight subunits
†††††† and a group of low-molecular-weight subunits.† This
†††††† only occurs for the glutenin fraction when you
†††††† reduce the disulfide bond.
†††††††††††††††† DR. KASARDA:† This is a two-dimensional
†††††† pattern, electrophoretic pattern, of the gluten
†††††† proteins.† All you have to recognize is that each
†††††† spot here represents a separated protein.† There
†††††† are quite a
few different gluten proteins, and we
†††††† can count easily 50, 60, 70 spots in such a
†††††† pattern.† Therefore, there are at least 50, 60, 70
†††††† gluten protein components.
†††††††††††††††† We know from genomic studies that, in
†††††† fact, there are probably at least a hundred genes
††† †††coding for these proteins, and probably several
†††††† hundred genes coding for the proteins.† The loci in
†††††† the genome that code for these proteins are spread
†††††† out over about nine different loci in the genome.
†††††††††††††††† Now, as far as we know, all of these
†††††† gluten proteins are toxic in celiac disease.† This
†††††† group here (indicating) are the omega gliadins, and
†††††† they seem to be particularly active.
†††††††††††††††† However, all of the gluten proteins have
†††† ††been tested by Paul Ciclitira's group and
†††††† Peter Howdle's group in the U.K., and they all
†††††† indicated by direct installation into the small
†††††† intestine that these proteins, all of these
†††††† different classes are toxic.
†††††††††† ††††††These omega gliadins are noted for being
†††††† strong allergen in exercise-induced anaphylaxis.
†††††† They are
one of the really strong antigens involved
†††††† in that particular allergy.
†††††††††††††††† DR. KASARDA:† This is a schematic diagram
†††††† that illustrates the fact that all of these
†††††† proteins are noted for a repetitive domain in which
†††††† certain amino acid sequences are repeated over and
†††††† over again.
†††††††††††††††† They are somewhat degenerate, but we can
†††††† derive consensus sequences.† These are glutenin
†††††† subunits, gamma-type gliadins.† These red,
†††††† staplelike lines indicate intramolecular disulfide
†††††††††††††††† In a glutenin subunit, we also have free
†††††† cysteines which can link up to another molecule to
†††††† form these higher-level polymers.† For example,
†††††† here is an alpha-gliadin -- I'm going to talk about
†††††† this a little bit more -- the end terminal, or the
†††††† first half of the molecule, is made up of these
†††††† repeating sequences.
†††††††††††††††† The second half is not repetitive and
†††††† contains most of the disulfide bonds.† Toxicity
†††††† seems pretty likely to be limited to the
†††††† regions.† These are the high-glutamine, the
†††††† high-proline regions.
†††††††††††††††† Now, the omega-type gliadin seems to have
†††††† lost -- well, we are not entirely sure whether they
†††††† lost this type of domain or not, but in any case
†††††† they are made up almost entirely of repeating
†††††††††††††††† DR. KASARDA:† This is a hypothetical model
†††††† of the gluten polymer or glutenin in which the
†††††† subunits are joined by intermolecular disulfide
†††††† bonds, there are also these intramolecular
†††††† disulfide bonds, to form a higher-level polymer
†††† ††that provides elasticity to a dough.
†††††††††††††††† The gliadins and the glutenins are
†††††† cohesive with one another, but the gliadins
†††††† contribute more to the extensibility of the dough,
†††††† and the elasticity comes primarily from the
†††††† glutenin fraction.
†††††††††††††††† DR. KASARDA:† Now, here I show some of the
†††††† types of
sequences that you find in the repeats.†
†††††† Now, they look pretty similar, a lot of glutamine,
†††††† which is represented by "Q"; a lot of proline
†††††† represented by "P"; and usually an aromatic
†††††† residue, either phenylalanine, "F," or tyrosine,
†††††††††††††††† Somewhere, and these are often degenerate.
†††††† They are not exactly according to the consensus
†††††† that I show here.† Somehow along the line these
†††††† sequences have acquired toxicity in celiac disease.
†††††††††††††††† DR. KASARDA: †Now, this is the complete
†††††† sequence of an alpha gliadin.† This is the
†††††† end-terminal region up here (pointing).† It starts
†††††† at one, and there are 263 amino acid residues.
†††††† Here, note the predominance of the blue Q's and the
†† ††††red P's for the proline and glutamine residues.
†††††††††††††††† This half of the molecule here is the
†††††† repeat region.† There is also this interesting set
†††††† of glutamines, which really hasn't been studied in
†††††† celiac disease.† It is probably not toxic, but, as
†††††† I say, there has been almost no study of this
polyglutamine stretch here.
†††††††††††††††† Note also these vertical lines here which
†††† ††I show.† Those are sites that we have observed
†††††† where cleavages occur with gastric enzyme, pepsin
†††††† and pancreatic enzymes, trypsin and chymotripsin.
†††††††††††††††† Now, most proteins would be broken down by
†††††† the digestive enzymes into single amino acids or
†††††† very small peptides: diatride, tetrapeptides that
†††††† are easily absorbed, which are probably not toxic.
†††††††††††††††† DR. KASARDA:† In the case, as Dr. Murray
†††††† mentioned, because we have a lot of proline which
†††††† interferes with the breakdown by the proteolytic
†††††† enzymes, we can get some pretty large stretches.
†††††† This stretch here from 31 to 55 right here is
†††††† something that we have tested as toxic.
†††††† ††††††††††Other people have dealt with sequences
†††††† from this stretch and found them also to be at
†††††† given toxic.† The fact that this gliadin and
†††††† glutenin proteins are difficult to digest by the
†††††† digestive enzymes allows these toxic stretches to
†††††† exist longer than you would find for other
†††††††††††††††† Now, this half of the molecule has a fair
†††††† amount of glutamine and proline, but as far as we
†††††† know toxicity does not reside in this C-terminal
†††††† half or sort of the end of the molecule.† It is in
†††††† sort of the forward end of the molecule.
†††††††††††††††† DR. KASARDA:† Now, this is what I would
†††††† call my string of beads model in which I have just
†††††† taken that sequence, 1 to 263, and shown it as
†††††† beads on a string.
†††††††††††††††† Each bead represents a different amino
†††††† acid.† I tried to assign the different amino acids
†††††† different code words to distinguish them.† This is
†††††† the end terminal region of repeats.† This
†††††† C-terminal where we have the disulfide bonds here.
†††††† Toxicity resides in this part here.
†††††††††††††††† This sequence here from 31 to 43 was
†††††† synthesized by Mike Marsh in the U.K. first, and he
†††††† instilled the synthetic peptide directly into the
†††††† small intestine of several celiac patients and
†††††† found changes in the mucosa that were indicative of
disease.† So this does seem to be a
†††††††††††††††† Here I show a computer molecular model of
†††††† what that sequence would look like in the
†††††† polyproline II left-handed helical confirmation
†††††† that Dr. Murray mentioned.† We think that these
†††††† peptides do have a strong tendency to assume this
†††††† polyproline II confirmation.
†††††††††††††††† Here, I show the sequence in three-letter
†††††† code as a string of beads model and here just a
†††††† single-letter code.† I know most people are not
†††††† used to dealing with these codes.† I apologize for
†††††† using them in some of the slides, but often I am
†††††† just trying to make a general point, and you don't
†††††† really have to follow the sequences according to
†††††† their exact correlations with the amino acids.
†††††††††††††††† DR. KASARDA:† Now, this is a list of some
†††††† of the either toxic or immunoactive peptides that
†††††† have been described in the literature.† This is
†††††† from Sean, et al, from Chaitan Khosla's lab at
†††††† Stanford.† The 33-Mer appears to be a very active
sequence.† I have indicated some
sort of homology
†††††† here by the yellow boxes here.
†††††††††††††††† All of these sequences, with the exception
†††††† of this one, have been found to be toxic by direct
†††††† installation into the small intestine or they have
†††††† been found to stimulate T-cells, T-cell clones,
†††††† derived from biopsies of celiac patients.
†††††††††††††††† These are just some of the toxic
†††††† sequences.† We don't know all of the toxic
†††††† sequences at this point.† There are certainly
†††††† others to be found, so it is a pretty complicated
†††††† situation in trying to sort out exactly what it is
†††††† about the sequences that produces toxicity in
†††††† celiac disease.
†††††††††††††††† DR. KASARDA:† Now I want to move on and
†††††† talk a little bit about the other grains.† If we
†††††† start with the class flowering plants, which is one
†††††† of the major divisions or plants in terms of
†††††††††††††††† We go down to the major two subclasses,
monocotyledones plants and dicotyledones plants.†
†††††† We can follow the monocots down to the Gramineae or
†††††† the grass family.
†††††††††††††††† Here, we have only wheat, rye and barley
†††††† that are toxic.† Triticale is a cross between wheat
†††††† and rye, and so would be expected to be toxic.
†††††††††††††††† Now, oats I have had to put in both
†††††† columns, and I will explain why.† There are many
†††††† other grasses in which the grains do not have toxic
†††††† proteins as far as we know.
†††††††††††††††† There are only two grains that have been
†††††† studied with modern methods and modern approaches
†††††† to understanding their relationship to celiac
†††††† disease, and that is wheat and oats.
†††††††††††††††† These others have often been studied very
†††††† minimally including rye and barley, but rye and
†††††† barley do contain proteins that have sequences
†††††† quite close to those in wheat.
†††††††††††††††† We assume that rye and barley are probably
†††††† toxic grains according to the early results of
†††††† Dicke in the Netherlands back around 1950, where
†††††† they considered rye, barley and oats as part of the
†††††††††††††††† Now about 15 years ago, I suggested that
†††††† if there are only a few grasses that contain the
††††† †toxic sequences, and they are closely related as
†††††† you will see, and then there are many other grasses
†††††† that do not contain the toxic sequences.
†††††††††††††††† I suggested that if you get into the dicot
†††††† group -- the buckwheat, quinoa, amaranth, and these
†††††† other grains -- it would not be toxic, simply
†††††† because of their distant taxonomic relationship to
†††††††††††††††† I was a little bit apprehensive about
†††††† suggesting this, but over the past 15 years since I
†††††† suggested this, people have been eating these other
†††††† grains.† As far as I know, there hasn't been any
†††††† serious indication that these do, in fact, have
†††††† toxicity for celiac patients.
†††††††††††††††† There have been some very fine studies
†††††† from Finland and throughout the world, indicating
†††††† that oats were safe for celiac patients.† But
†††††† towards the end of last year the Oslo, Norway,
†††††† group under Knut Lundin and Ludvig Sollid.† They
†††††† have found
-- well, I'm getting a little bit ahead
†††††† of myself.† Let's deal with this slide first.
†††††††††††††††† DR. KASARDA:† If we take a subfamily,
†††††† festucoidiae, of the grass family and we look at
†††††† the tribal level, and I made this slide before the
†††††† results from Oslo were published.† The hordeae --
†††††† which includes wheat, rye, and barley -- were one
†††††† tribe.† I thought that oats were probably
†††††† non-toxic, so I put them in -- well, they belong in
†††††† a separate tribe.† It was only this one tribe that
†††††† had the toxic sequences.
†††††††††††††††† Now, it is pretty certain that the oats
†††††† are toxic to a few probably rare individuals, but
†††††† we don't really know how this works out.† They
†††††† found three celiac patients who definitely reacted
†††††† to oats by the same mechanism that they reacted to
†††††† gliadin peptides.† This, I think, was pretty well
†††††† demonstrated by the work from Norway.
†††††††††††††††† Now, here I show the proteins that you
†††††† find in wheat, gamma-type gliadins and related
†††††† low-molecular-weight glutenin subunits, they are
†††††† found in
rye, barley, not in oats.† Alpha-type
†††††† gliadins are found in wheat, but you don't find
†††††† them in rye and barley or in oats, and so on down
†††††† the line.
†††††††††††††††† Now, the avenins are a small fraction of
†††††† the total proteins in oats.† These make up only
†††††† about 10 percent of the protein.† Most of the
†††††† protein is oat globulin, which as far as we know if
†††††† not harmful or toxic to celiac patients.† There are
†††††† low-molecular weight proteins related to the
†††††† avenins in rye, barley, and wheat.
†††††††††††††††† DR. KASARDA:† Now, this is another one of
†††††† those sequence slides, but let me just try to make
†††† ††a few points here.† This top sequence is a gliadin
†††††† sequence.† It starts here (indicating) and runs
†††††† down to here.
†††††††††††††††† The bottom sequence is an avenin, which
†††††† shows a lot of homology with the C-terminal half of
††††† †this gamma-gliadin molecule.† This is also true for
†††††† the alpha gliadins.† Where the amino acids are the
†††††† same, I have colored them in blue.
There is a lot of homology here in the
†††††† C-terminal half, but that is not where the toxicity
†††††† lies.† The Oslo group has shown that this
†††††† particular sequence, which I have underlined, does
†††††† have certain characteristics including glutamic
††† †††acid at key positions that are important, as Dr.
†††††† Murray pointed out, for binding to MHC proteins.
†††††††††††††††† Consequently, most of the repeat region is
†††††† absent from the avenins.† There is just this sort
†††††† of residual section here, which does have a lot of
†††††† glutamine and a lot of proline and some key
†††††† glutamic acid sequences or amino acids that seem to
†††††† be responsible in these few patients that have been
†††††† studied for the toxicity.† This sequence is
†††††† certainly capable of stimulating T-cell clones from
†††††† these patients.
†††††††††††††††† I think that the evidence is pretty good
†††††† that there are at least a few -- it seems as though
†††††† there are probably rare individuals who respond to
†††††† oats and probably most celiac patients do not
†††††† respond to oats.
†††††††††††††††† This is a rather puzzling situation,
†††††† because I
have always thought of the proteins as
†††††† being pretty definitive for celiac disease, that
†††††† all celiac patients reacted to wheat and probably
†††††† to rye and barley, and that this was part of the
†††††† definition of celiac disease.
†††††††††††††††† Now we have a situation here where it
†††††† appears that some patients react to oats and some
†††††† don't.† This is some ongoing research that needs
†††††† some elucidation.
†††††††††††††††† DR. KASARDA:† Just to jump back into the
†††††† classification, this is another subfamily,
†††††† panacoideae.† Here we have maize and sorghum and
†††††† millet.† We have actually done a little bit of
†††††† end-terminal sequencing on sorghum and millet
†††††† proteins, and they do seem fairly close to the maze
†††††† protein.† This would explain to some degree why
†††††† they are not toxic in celiac disease.† As far as we
†††††† know, it is still wheat, rye, and barley that are
†††††††††††††††† DR. KASARDA:† Now, this is my last slide.
currently favored method for determination of
†††††† gluten in food is the R5 monoclonal antibody ELISA
†††††† test developed by Mendez in Spain.† This seems to
†††††† be a pretty good test; it is not perfect.
†††††††††††††††† The antibody reacts to monomeric wheat,
†††††† rye and barley prolamins, but not the oat avenins,
†††††† and it reacts weakly or not at all with the
†††††† glutenin or glutelin, pretty good sensitivity,
†††††† recognizes these particular motifs more strongly,
†††††† although some others that are similar are
†††††† recognized weakly.
†††††††††††††††† The Codex Committee on Methods agreed in
†††††† 2004 to endorse temporarily the R5 ELISA for the
†††††† determination of gluten.† Now, there are some
†††††† possible problems.† There is the failure to detect
†††††† the glutenin proteins.
†††††††††††††††† In some preliminary work from our
†††††† laboratory, for example, when we look at wheat
†††††† starch that is intended for use by celiac patients,
†††††† we find that the gliadins are pretty well washed
†††††† out, but we do find evidence of
†††††† high-molecular-weight glutenin subunits attached to
†††††† the starch
surface.† These would not be picked up
†††††† by the R5 ELISA.
†††††††††††††††† Then, there is the question about small
†††††† peptides from hydrolases.† There has been some work
†††††† described using a competitive assay, which might
†††††† possibly solve the problem of the small peptides
†††††† from hydrolases.
†††††††††††††††† Also, there is a certain amount of data
†††††† indicating differences in the results from
†††††† different labs on the same sample.† On the whole,
†††††† it seems like a pretty good test that can be used.
†††††† As I say, it is not perfect, but it is a pretty
†††††† impressive test on the whole, and it may be as
†††††† close as we are going to get.
†††††††††††††††† Although, I certainly can think of some
†††††† ideas for maybe improving it.† At any case I think
†††††† I will end my talk here and I thank you very much
†††††† for your attention.
†††††††††††††††† CHAIRMAN DURST:† Thank you.
†††††††††††††††††††††† QUESTION AND ANSWER SESSION
†††††††††††††††† CHAIRMAN DURST:† Are there questions?
†††††††††††††††† Okay.† Margaret?
DR. BRILEY:† Margaret
Briley.† Can you
†††††† give us any idea of the use of this ELISA test by
†††††† industry in terms of the frequency and the
†††††† acceptance and willingness to do it?† Do you have
†††††† any feel for that?
†††††††††††††††† DR. KASARDA:† Well, I think it is being
†††††† used, and Dr. Collin can comment on this,
†††††† extensively used in Europe and it is becoming used
†††††† in the U.S.† Susan Hefle, who spoke yesterday, I
†††††† think that they have done a certain amount of work
†††††† using this test for industry.
†††††††††††††††† My impression is that not much testing is
†††††† done in the U.S.† Maybe Cynthia could comment on
†††††† that.† I think it is developing, but we are quite a
†††††† bit behind the Europeans in terms of a willingness
†††††† to test and desire to test products and make sure
†††††† that they are as close to gluten-free as they
†††††† possibly get.† I can't give you a definitive
†††††† comment on that.† I haven't made any surveys.
†††††††††††††††† CHAIRMAN DURST:† Any further questions or
DR. CALLERY:† Pat Callery.† Thank you for
†††††† the review of the relevant biochemistry.† Could you
†††††† relate the transglutaminase substrate specificity
†††††† to these various glutamine-containing --
†††††††††††††††† (Simultaneous discussion.)
†††††††††††††††† DR. KASARDA:† Not personally, but other
†††††† people have.† There are certain sequences that are
†††††† susceptible to deamidation and probably
†††††† transamidation as well.† These have been described
†††††† in some recent publications.† There are many sites
†††††† in the gliadins that are susceptible to
†† ††††††††††††††DR. CALLERY:† The transglutaminase I
†††††† understood was an important feature in binding
†††††† these proteins and causing the --
†††††††††††††††† (Simultaneous discussion.)
†††††††††††††††† DR. KASARDA:† Well, you know, in the MHC
†† ††††proteins there is a positive charge in the binding
†††††† pocket that binds well to a negatively charged
†††††† glutamic acid.† This does enhance the strength of
†††††† the binding to the binding site of DQ2/DQ8.
†††††††††††††††† Now, I didn't get into it, although
someone else will, there seems to be two
†††††† legs to the celiac disease situation.† There is the
†††††† adaptive immune system, which has been worked on
†††††† quite a bit in terms of this presentation of
†††††† gliadin peptides to T-cells, to the T-cell
†††††† receptor, and stimulation along that leg.
†††††††††††††††† However, one of the peptides I described
†††††† that Mike Marsh had studied, that particular
†††††† peptide is not immunoactive.† It does not stimulate
†††††† the T-cells, yet when instilled directly into the
†††††† small intestine it produced changes that were
†††††† characteristic of celiac disease.
†††††††††††††††† In the last couple of years, there has
†††††† been an interest in the role of the innate immune
†††††† system in possibly triggering the first leg of
†††††† celiac disease, which then progresses on to involve
†††††† the adaptive immune system and the CD4 T-cells of
†††††† the lamina propria.
†††††††††††††††† I think that part is becoming pretty well
†††††† understood.† Ludvig Sollid and his co-workers,
†††††† while he was on sabbatical at Stanford, they
†††††† actually crystalized a DQ2 with the gliadin peptide
†††††† in the
binding site.† They have defined a
†††††† characteristics of the peptides that are important
†††††† for binding.
†††††††††††††††† However, I think we still don't understand
†††††† a good part of what is active or toxic about these
†††††† peptides, and it may have to do with this
†††††† triggering and innate immune response.† That is
†††††† research that is really developing right now.
††††††††††††† †††CHAIRMAN DURST:† Soheila.
†††††††††††††††† DR. MALEKI:† Soheila Maleki, USDA.
†††††† Essentially, the substrate for the transglutaminase
†††††† is the same peptide that is presented by the
†††††† antigen-presenting cells?
†††††††††††††††† DR. KASARDA:† Well, after you deaminate a
†††††† particular glutamine, then the binding strate goes
†††††† up for the receptor site on the MHC protein.
†††††††††††††††† DR. MALEKI:† Essentially, it is the same
†††††† substrate, just after deamination --
††††† †††††††††††(Simultaneous discussion.)
†††††††††††††††† DR. KASARDA:† Well, there is also the
†††††† question of, Why do you have antibodies to the
†††††† transglutaminase?† This may involve transamination
where you get a binding of gliadin in the
†††††† transglutaminase, and then this triggers the
†††††† apparent autoimmune antibodies to transglutaminase.
†††††††††††††††† DR. MALEKI:† I see.† Well, I just find it
†††††† amazing that when you show the lineup of the
†††††† peptides, the homology, that you had a two amino
†††††† acid difference and went from immunoreactive to
†††††† non-toxic.† I'm sure by now they probably can
†††††† explain that?
††††††††††††† †††DR. KASARDA:† No, they can't.
†††††††††††††††† DR. MALEKI:† Well, even in the fitting up
†††††† to the transglutaminase or to the processing by
†††††† antigen-presenting cells?
†††††††††††††††† DR. KASARDA:† Well, it is very puzzling,
†††††† very interesting.† I really can't answer your
†††††††††††††††† DR. MALEKI:† Thank you.
†††††††††††††††† CHAIRMAN DURST:† Any further discussion?
†††††††††††††††† (No verbal response.)
†††††††††††††††† CHAIRMAN DURST:† All right.† Thank you,
†††††† Dr. Kasarda.
†††††††††††††††† We are now scheduled for a break.† We are
†††††† just about
on schedule, so we will take a brief
†††††† break and reconvene at 10:45.
†††††††† ††††††††(Thereupon, from 10:25 a.m. to 10:45 a.m.,
†††††† there was a pause in the proceedings.)
†††††††††††††††† CHAIRMAN DURST:† Our first speaker after
†††††† the break is Dr. Alessio Fasano, professor of
†††††† pediatrics, medicine and physiology and director of
†††††† the Mucosal Biology Research Center, Center for
†††††† Celiac Research, University of Maryland School of
†††††††††††††††††††††††††† PROSPECTIVE STUDIES
†††††††††††††††† DR. FASANO:† Thanks so much.† I've got to
†††††† do this.† I need really to thank the FDA, who has
†††††† been so kind to invite me, but also to be so
†††††† sensitive to use Italian candies.
†††††††††††††††† DR. FASANO:† This is very nice of you
†††††† guys, and we appreciate that.† I also want to tell
†††††† you guys that because of the other speakers, I
†††††† decided to reduce a little bit my talk, so a few
†††††† slides have been taken out from the handouts to go
†††††† straight to the point.
††††††††††† †††††There has been a general perception that
†††††† this is a quite young disease, in other words,
†††††† something that we are dealing with kind of
†††††† recently. I want to put this in the right
†††††† perspective and give you some of the background to
†††††† justify this prospective study to decide what is
†††††† threshold of tolerable gluten.
†††††††††††††††† First of all, believe it or not the first
†††††† trace of a description of this disease goes back to
†††††† the Roman Empire.† This is not something that has
†††††† happened in the last few years.
†††††††††††††††† DR. FASANO:† Who really put the disease on
†††††† the map is this fellow here.† Samuel Gee, at the
†††††† end of the past century, around 1890, gave an
†††††† historical lecture to a place where I had the
†††††† privilege to study for a little while at Saint
†††††† Bart's Hospital in London.
†††††††††††††††† He really put celiac disease on the
†††††† "scientific map."† I took little sentences here and
†††††† there from his lectures to give you the sense of
†††††† how this guy got the story right more than 120
†††††† years ago.
†††††††††††††††† He described these as a chronic
†††††† indigestion that is met in every single age.
†††††† Again, our misconception in the past was celiac
†††††† disease was confined to a specific age group.† He
†††††† knew already that was not the case; it can affect
†††††† at any age.
†††††††††††††††† Of course, it is particularly more
†††††† frequent in all kids between one and five years
†††††† old, and that was the observation at the time.† He
†††††† spent time and effort to clarify the fact that
†††††† everybody can be affected.
†††††††††††††††† Now, symbiotics, hands-on, was the way to
†††††† do a disease diagnosis at that time.† We didn't
†††††† have a lot of sophisticated tools, so it was really
†††††††††††††††† For a gastroenterologist, dealing with a
†††††† problem like that means describing feces, stools,
†††††† and that's what it is.† He introduced with this
†††††† description a very important concept about celiac
†††††† disease in terms of classical GI presentation,
In other words, right before they would
†††††† know about the genetics, right before they would
†††††† know about the grains, the eyes are telling us that
†††††† the feces are loose, malformed, but not watery,
†††††† definitely more bulky than the food taken seems to
†††††† account for, i.e., malabsorption.
†††††††††††††††† What is remarkable is this part here.† He
†††††† ventured also to understand what was the
†††††† pathogenesis of the disease and introduced two
†††††† concepts: the genetics and environmental trigger.
†††††††††††††††† He said kids that suffer from it are not
†††††† all weak in constitution, errors in diet.† I want
†††††† to clarify that the first time that the link
†††††† between celiac disease and grains was made was soon
†††††† after World War II.† Until then we had no clue
†††††† whatsoever what was the trigger leading to celiac
†††††††††††††††† The link was made during World War II
†††††† because there was a higher rate of mortality among
†††††† kids in Middle Europe that was not explained.
†††††† During World War II, grains were not available
They were fed with potato starch, potato
†††††† flour, and the mortality dropped dramatically, to
†††††† reappear after the end of the war when flour was
†††††† again available.† That is when the link was made.
†††††††††††††††† This guy is already there.† Errors in diet
†††††† may be perhaps a cause, but whatever.† Why, out of
†††††† a family of kids all brought up in a much similar
†††††† way, should only one suffer?
†††††††††††††††† Again, he is trying to understand what is
†††††† the genetic component, what is the environmental
†††††† component, why some people have got it and some not
†††††† from the same family eating the same stuff.
†††††††††††††††† Then, he finished up by saying, "Okay, I
†††††† think that I have a way to get to the bottom line
†††††† in treatment.† The treatment has to be regulating
†††††† food in the main part of the treatment.† It is
†††††† amazing if you come already with this conclusion.
†††††† The allowance of farinaceous food must be small.
†††††† Again, I find this remarkable.† Highly starchy
†††††† food, rice, sorghum, corn-flour are unfit.
†††††††††††††††† Now he is losing himself a little bit when
†††††† he says malted food is better.†† Also, rusks or
provided it is cut thin and well-toasted on
†††††† both sides, will be all right.
†††††††††††††††† Grant him the benefit of that.† I believe
†††††† that, again, in 1890 making this kind of statement,
†††††† even if he [made] this little boo-boo here, I think
†††††† that it is absolutely remarkable.
†††††††††††††††† DR. FASANO:† Now, fast forward that 120
† †††††years later, and that is what we understand about
†††††† celiac disease.† You heard from Dr. Kasarda and
†††††† Dr. Murray already that this is an immune-mediated
†††††††††††††††† It is not an allergic reaction, but rather
††††† †right now we really truly believe that this is an
†††††† autoimmune condition.† In other words, we are in
†††††† the same kind of range as multiple sclerosis, type
†††††† 1 diabetes, and so on and so forth.
†††††††††††††††† Therefore, as such there are two key
†††††† elements to develop the disease:† You have to be
†††††† genetically susceptible.† I'm not going to spend
†††††† more time about this DQ2/DQ8, but they are the
†††††† docking station, the "eyes," of the autoimmune
†††††† system to
see the trigger from the environment
†††††† coming in.
†††††††††††††††† It is unique because the only other
†††††† autoimmune disease for which we know everything
†††††† specifically is the only autoimmune disease for
†††††† which we know the trigger, that is, gluten.
†††††††††††††††† I wish that we had that kind of
†††††† information for other autoimmune diseases, for
†††††† which we will have a solution.† Theoretically, we
†††††† have on hand the possibility of treatment of this
†††††††††††††††† However, I will argue that unless we have
†††††† a clear rule of engagement, i.e., a food labeling
†††††† bill that will really clearly define what is
†††††† "gluten-free," this is a theoretical solution but
†††††† very difficult to put in practice.
†††††††††††††††† DR. FASANO:† Again, it is pretty obvious
†††††† that you have to have these two ingredients, you
†††††† have the genes and you have to have the grains.
†††††† When they interplay, you may end up developing
†††††† celiac disease.
We heard already that variability in terms
†††††† of the timing, how long it is going to take, the
†††††† outcome in terms of symptoms, and so on and so
†††††† forth, is unbearable.† However, they are all under
†††††† the same kind of umbrella of celiac disease.
†††††††††††††††† What are our treatment options at the
†††††† moment?† If these two elements are absolutely
†††††† necessary to developing the disease, I believe it
†††††† is a no-brainer, it is pretty simple, there are
†††††† only two solutions.
†††††††††††††††† First, we can remove the genes, and I
†††††† don't think that we can do that.† We are not quite
†††††† there yet anyhow.† As Dr. Murray explained, we know
†††††† some of them but we don't know all of them.† Or,
†††††† secondly, we eliminate the grains.† Those are the
†††††† options that we have available.† There is no other
†††††† way to turn from this.
†††††††††††††††† Don Kasarda went extensively into this.† I
†††††† didn't know that he was invited, by the way.
†††††† However, the bottom line is the only treatment
†††††† right now is strict, lifelong -- as you heard, you
†††††† don't grow out of this, so you have got to endure
†††††† it for the
rest of your life -- avoidance of wheat,
†††††† rye and barley.† The oats story, again, I am not
†††††† going to go back because you heard about that.
†††††††††††††††† DR. FASANO:† It is pretty obvious what are
†††††† the major sources of gluten.† This is the easy part
†††††† when you have to deal with the patients freshly
†††††† diagnosed.† It is easy to say, "You know what?† No
†††††† bread, pasta, pizza, beer, cookies, muffins, and so
†††††† on and so forth.
†††††††††††††††† DR. FASANO:† This is a little bit more
†††††† complicated, and that is where I believe a food
†††††† labeling bill will help.† Of course, it is not
†††††† necessary to go and say, "You know what?† This
†††††† muffin that you buy at the bakery needs a label."
†††††† We know that already whether it is gluten-free.
†††††††††††††††† However, this stuff here (showing "Sources
†††††† of Gluten" slide) definitely needs a label, some of
†††††† them, because it is not clear if they have gluten
†††††† or not because they can be processed with or
†††††† without gluten.
Gluten is a formidable, extremely cheap
†††††† biological glue.† Don told you the physical,
†††††† chemical characteristics of the molecule.† The
†††††† reason why manufacturers use that is because when
†††††† you have two elements of a processed food that does
†††††† not stick together, the cheapest way to keep them
†††††† together over time is to use gluten.† Right now,
†††††† the label can see just the nature of flavor but not
†††††† gluten, not necessarily so.
†††††††††††††††† Then, there are really the tough ones in
†††††† which, this is not even food really, a source of
†††††† gluten needs to be considered.† I can't
†††††† conceptualize enough how many times we've gotten
†††††† E-mails of people asking, "Is my husband, who has
†††††† celiac disease, going to be sick or whatever," or
†††††† the Playdough for the kids in kindergarten, and so
†††††† on and so forth.† These are elements to keep in
†††††† mind that we deal with all the time.
†††††††††††††††† Of course, the big deal is right here --
†††††† medications, prescriptions.† As for foods,
†††††† processed foods, also medication they enjoy gluten
†††††† as an additive to keep elements together.
Now, while I was saying adhere to a diet
†††††† is a pure theoretical no-brainer, but in a
†††††† practical sense it is extremely complicated.† It is
†††††† a chronic intervention that you have to do, and you
†††††† have to stick with it with full commitment for the
†††††† rest of your life.
†††††††††††††††† Every single individual in this room I am
†††††† pretty sure that you have made some commitments
†††††† here and there to go on a certain diet or to
†††††† exercise or to decide to change your lifestyle.† To
†††††† keep that constantly for the rest of your life, it
†††††† takes a lot of stamina.† That is the reality of the
†††††††††††††††† That is true particularly in the American
†††††† society in which any chronic illness will require
†††††† chronic treatment, whether it be diet or exercise
†††††† or medication or whatever, will pose a problem of
†††††† compliance.† Definitely among different
†††††† interventions, a diet compliance can be really a
†††††† difficult aspect of treatment.
†††††††††††††††† In my book, food is one of the few joys in
†††††† life.† How many times do we leave home and go to
††† †††work, we drive, we don't think about it,
†††††† find ourselves at work without having to pay
†††††† attention to directions, streets, and so on and so
†††††† forth?† We are used to it.
†††††††††††††††† That is the same with food, we are used to
†††††† it.† However, that is not the case for celiacs
†††††† because they have to think about this over and over
†††††† and over again.† It will become not a natural,
†††††† spontaneous activity in life, but it will become a
†††††† very, very demanding operation.
†††††††††††††††† DR. FASANO:† Why don't people stick with
†††††† diets?† This is a survey that was done in
†††††† Upstate New York.† This statement, and this is just
†††††† to paraphrase something that Cynthia was telling
†††††††††††††††† "If I eat less gluten, I will have less
†††††† intestinal damage."
†††††††††††††††† Half of the people say, "You know what?† I
†††††† really don't have to stay a hundred percent gluten
†††††† free.† As far as I decrease this, I will have less
†††††† problems.† I will be all right."
"I've lived this long eating gluten, how
†††††† much will a gluten-free diet really help me now?† I
†††††† mean, you know, if it's not been a big deal so far,
†††††† why should I just dramatically change my lifestyle?
†††††† I've survived so far, I'm not going to die from
†††††††††††††††† "It's not me, that I have to do this.
†††††† It's my doctor who should tell me when I need
†††††† follow-up testing or whether I need to stick with a
†††††† diet, and so on and so forth."† One-fourth of the
†††††† people say that.
†††††††††††††††† Again, you heard Dr. Murray, that
†††††† unfortunately some of the confusion is generated by
†††††† the professionals, the healthcare professionals.
†††††† They don't know the rule of the game, and,
†††††† therefore, they cannot transmit how to play the
†††††††††††††††† It is pretty much the sense that you go to
†††††† the doctor as an individual that has to teach you
†††††† how to play chess, and this fellow has no clue
†††††† whatsoever how to move the pieces.† Patients have
†††††† to learn how to play chess while playing against a
professional player.† How fair is
that?† It is an
†††††† ongoing process.
†††††††††††††††† This is the one that disturbed me the
†††††† most:† "Scientists and doctors still haven't proven
†††††† that gluten really hurts them."† You know, there is
†††††† no clear information that gluten is dangerous to
†††††† celiacs, and that is quite disturbing.
†††††††††††††††† DR. FASANO:† What are the current barriers
†††††† in compliance?† Again, you heard about the emotion
†††††† of the person, anxiety.† There is a tremendous
†††††† reaction when you are diagnosed with a chronic
†††††† illness, no matter how you want to put it.† Now,
†††††† grief and fear and denial are part of the story.
†††††††††††††††† The ability to resist temptation and to be
†††††† disciplined on a gluten-free diet is tough.† There
†††††† are feelings of deprivation.† A few years ago I was
†††††† with one of the patients, and he got the chance to
†††††† drink a gluten-free beer.† Soon after he started to
†††††† drink the beer, I saw tears coming down his cheeks.
†††††† His simple statement was, "I've waited 25 years for
†††††† this."† Imagine, 25 years to drink again beer.
He was disciplined, and he didn't touch
†††††† it.† However, there are many others, particularly
†††††† adolescents, in which that kind of discipline is
†††††† really hard to obtain.
†††††††††††††††† This is very much the heart of the
†††††† problem, fear generated by inaccurate information.
†††††† If we do not have clear ideas, we, as
††† †††professionals, and one says black and the other one
†††††† says white, and the other one says up and the other
†††††† one says down, that creates a lot of confusion and
†††††† a lack of trust.
†††††††††††††††† DR. FASANO: †Other barriers to compliance
†††††† are of course we live in a society that drives 150
†††††† miles an hour, and we don't have the time to seek
†††††† to prepare our food to enjoy.† My kids consider
†††††† that the stove is the microwave.† The stove does
†††††† not exist.
†††††††††††††††† Cynthia teaches us the fact that the new
†††††† generation believes that cooking is just powder
†††††† mixed with water, stick it in the microwave, and
†††††† the only thing that you've got to do is read how
†† ††††long should that go on and that's it.† What
†††††††††††††††† Here, assessing gluten content in food and
†††††† label reading is the most compelling change in
†††††† lifestyle that these people go through.† Right now,
†††††† I don't know about you guys, but I don't enjoy food
†††††† shopping.† I really do not.† I tend to go at
†††††† midnight when nobody is there, because I want in
†††††† and I want out.
†††††††††††††††† That is not an option for celiacs.† One
†††††† thing that will take you, I don't know, half an
†††††† hour will take four or five hours for celiacs
†††††† because you've got to read every single label to
†††††† the nitty-gritty and make decisions.
†††††††††††††††† Many times now I see people with cell
†††††† phones calling an 800-number right there on the
†††††† spot saying, "I have your Box XYZ, is this
†††††† gluten-free or not?"† It is cumbersome.
†† ††††††††††††††DR. FASANO:† All of this to come to the
†††††† heart of what I'm going to share with you guys.
†††††† How much is too much?† Unfortunately, I can't
conceptualize and stress enough what Cynthia
†††††† already said.† In biology, the absolute zero does
†††††† not exist.† If you really do believe that we can
†††††† achieve zero as gluten-free, this is a pure
†††††† theoretical concept that nobody will ever be able
†††††† to achieve.
†††††††††††††††† Assume, just for a moment, that we will
†††††† have a sophisticated,† super-duper sophisticated,
†††††† monoclonal ELISA to really go down to zero.† To
†††††† manufacture food in that way, people in that
†††††† particular factory should be dressed with spray
†††††† suits, all antiseptic.† A piece of bread will cost
†††††† $250, because that is what that level of
†††††† sophistication and controlled environments will
†††††† take.† Consequently, it is impossible.
†††††††††††††††† At the same time we need to give industry,
†††††† manufacturers, a parameter of what is tolerable and
†††††† what is not.† There have been many retrospective
†††††† studies that Dr. Collin is going to tell us about,
†††††† very few prospective studies because they are
†††††† extremely challenging to do right.
†††††††††††††††† This study that I am going to show you the
†††††† data of has
really been coordinated by
†††††† Dr. Carlo Catassi, who has been involved in this
†††††† kind of topic for the past 15 years.† He is a
†††††† member of our center, and we have been doing this
†††††† in coordination for the past four years.
†††††††††††††††† Why do we need to do this?† Because again
†††††† this is a long-term, strict gluten-free diet.† If
†††††† we do a prospective study design, we can answer
†††††† questions that a retrospective study was not able
†††††† to answer.
†††††††††††††††† How we did this?† We did it in a way that
†††††† the gluten-free diet, people that come in are
†††††† already diagnosed on a gluten-free diet.† We are
†††††† monitoring this gluten-free diet in a blind fashion
†††††† where a given amount of gluten is added to the
†††††† diet, then, the clinical, serological and biopsy
†††††† evaluation before and after the microchallenge.
†††††††††††††††† The background noise, this is very
†††††† important, is caused by possible contamination of
†††††† the food was minimized by using a control group, in
†††††† other words, to really do this by the book.
DR. FASANO:† Studies done in the
†††††† example, from Dr. Catassi almost a decade ago,
†††††† showed a linear relationship between the amount of
†††††† gliadin -- that is the toxic part of the story here
†††††† -- a daily dose, and it causes damage between 100
†††††† and 1,000 milligrams a day.
†††††††††††††††† The intraepithelial lymphocytes -- and we
†††††† are going to go back to what these intraepithelial
†††††† lymphocytes are all about, the meaning -- was the
†††††† most sensitive index, not the serology and not the
†††††††††††††††† What you heard already from Dr. Murray is
†††††† that after all these red flags the antibodies may
†††††† not be sensitive enough to uncover exposure to
†††††† gluten.† Indeed, even 10 years ago this was very
††† †††††††††††††DR. FASANO:† Why do this again?† If it was
†††††† done 10 years ago, why revisit this if we have
†††††† already the information?† Several reasons.† The
†††††† need, first of all, to investigate the effects of
†††††† lower gluten doses.† Because at that time they were
†††††† using large
doses, because that was the level of
†††††† sensitivity of the tests for the foodstuff.
†††††††††††††††† There is a need for prolonging the
†††††† duration of the microchallenge.† In the past, the
†††††† longest that we went was a month, and people would
†††††† ask, "How about two months or three months?"
†††††††††††††††† How about if the period, the lag period,
†††††† between the exposure to gluten and when you react
†††††† is longer?† You believe it to be safe for one
†††††† month, but you keep going, and eventually you
†††††††††††††††† There is a need of a control group that
†††††† was never used before, and, most importantly, you
†††††† heard that gliadin is part of the story.† They are
†††††† the glutamines.
†††††††††††††††† If you do the study just as done in the
†††††† past, you may really not uncover what is really the
†††††† story; in other words, what you leave out there is
†††††† not pure gliadin but rather this mixture of
†††††† proteins that Don Kasarda was telling us about.
†††††††††††††††† DR. FASANO:† I don't want to spend too
†††††† much time
on this, but for a matter of
†††††† quantification, to give a sense of what we are
†††††† talking about.† In 200 grams of wheat-based
†††††† products -- bread, pasta, so on and so forth -- you
†††††† heard that the main proteic fraction in wheat is
†††††† gluten.† For 8 to 14 percent of the overall amount
†††††† is wheat.† Gluten is 75 percent of all the protein.
†††††† Between gluten and glutamine, we can say that all
†††††† of this 8 to 14 percent are these toxic proteins
†††††† for celiacs.† This 8 to 14 percent translates into
†††††† 15 grams.
†††††††††††††††† The real toxicity, the main toxic, is due
†††††† to the gliadins.† Again, glutamines contributed to
†††††† toxicity.† Of the 200 grams, 8 to 14 percent is
†††††† equal to 15 grams.† Half of it is gliadin.† Gliadin
†††††† has more than 50 toxic fragments, and so on and so
†††††††††††††††† If you go on a gluten-free diet, an adult
†††††† that is on a gluten-free diet, roughly, consumes --
†††††† I mean, in a normal diet, roughly, the amount that
†††††† you consume is this, 15 grams.† Roughly, you
†††††† consume 200 grams of wheat-based products.
If you are on a gluten-free diet, a
†††††† typical gluten-free diet, the subject consumes
†††††† gluten-free flour-based, that is roughly 80 grams.
†††††† The key element is how much of this 80 grams of
†††††† gluten-free products can be contaminated with the
†††††† toxic element, gluten?† How much is the amount that
†††††† you can tolerate?† That is the heart of the problem
†††††††††††††††† DR. FASANO:† That prompted the design of
†††††† the study.† It is a quite complicated study.† The
†††††† aim was to evaluate the consequences of the
†††††† protracting just minimal intake, either 10 of 50
†††††† milligrams, a very small intake.
†††††††††††††††† In a group of adult celiacs on long-term
†††† ††treatment with the gluten-free diet, why this
†††††† amount?† Because, again, 100 milligrams was already
†††††† tested and proved to be dangerous 10 years ago.
†††††††††††††††† How the study was designed was as a
†††††† multicenter, prospective randomized,
†††††† placebo-controlled, double-blind and was a
†††††† three-year study.† It was entirely sponsored by the
†††††††††††††††† The reason why we did it in Italy, as I
†††††† was mentioning before, is mainly because economical
†††††† support of such a complicated and expensive study
†††††† could be executed at this time only in a place
†††††† other than the United States where we don't have
†† ††††that kind of resources.
†††††††††††††††† DR. FASANO:† Who was eligible?† Patients
†††††† with biopsy-proven celiac disease had to be on a
†††††† gluten-free diet for at least two years.† These
†††††† people that had been diagnosed with all of the
†††††† criteria are accepted and have to be complying with
†††††† the diet for at least two years.
†††††††††††††††† If you are younger than 18 years old, poor
†††††† compliance, abnormal results at the baseline
†††††† evaluation or you have IgE deficiency, that will be
†††††† an exclusion criteria.
†††††††††††††††† DR. FASANO:† Now, how we did this?† Well,
†††††† again, these people were heroes to accept such a
†††††† study, but this was the only way to do it.† These
would come in to be scrutinized to see if
†††††† they were eligible.
†††††††††††††††† If they were eligible, a consent form was
†††††† obtained and there was an intense, strict
†††††† monitoring of their gluten-free diets for a month
†††††† before the beginning of the study was obtained.
†††††† Baseline clinical serological and a biopsy was
†††††† obtained.† In other words, they underwent a
† †††††endoscopy with a biopsy to show that they were
†††††††††††††††† They were blindly randomized in three
†††††† groups, either no gluten, 10 milligrams of gluten
†††††† or 50 milligrams of gluten.† They were followed for
†††††† three months.† At a monthly interval there was a
†††††† check with the serologist for symptoms.
†††††††††††††††† At the end of the study, at the end of the
†††††† three months, once again there was a clinical
†††††† evaluation and a serological evaluation and a
†††††† second intestinal biopsy under endoscopy.
†††††††††††††††† This was the kind of study that this was
†††††† the only way, given the fact that the we know
†††††† symptoms and serology tests cannot be sensitive
†††††† enough to
do this right.
†††††††††††††††† DR. FASANO:† The purified gluten was used
†††††† for the challenge.† Gluten -- or lactose-containing
†††††† placebo -- capsules were randomly prepared.† The
†††††† lab tests were centralized.† There was monthly
†††††† monitoring of adherence to the protocol; it was
†††††† checked by a nutritionist.
†††††††††††††††† Measurement of gluten contamination in
†††††† commercially available gluten-free food that they
†††††† had during the challenge was checked by ELISA.† The
†††††† serum AGA and anti-tTG antibodies were checked; a
†††††† biopsy was performed with morphometry; there was an
†††††† intraepithelial lymphocytes count; and control
†††††† biopsies from non-celiac patients were used.
†††††††††††††††† DR. FASANO:† These are the foods that they
†††††† had a gluten-free foods.† You keep in mind that in
†††††† Italy right now the food labeling policy is to be
†††††† labeled as gluten-free you have to have 20 parts
†††††† per million or less.
†††††††††††††††† Indeed, with this simple exception, the
majority of the foods that these people there
†††††† are eating was gluten-free, by definition of the 20
†††††† parts per million.
†††††††††††††††† Consequently, the only gluten that these
†††††† people were seeing was actually the ones that were
†††††† dealing with the challenge, if they were in the
†††††† group of gluten exposure.
†††††††††††††††† DR. FASANO:† We were able to recruit 39
†††††† people, who were divided equally into three groups.
†††††† There were a couple of things that were interesting
†††††† to us.
†††††††††††††††† Of all the parameters that we measure, two
†††††† are extremely important to establish the health of
†††††† the intestine and the exposure to gluten damage,
†††††† one was the villous height/crypt depth ratio.† It
†††††† is very typical use of morphometric analysis that
†††††† we do in clinical practice.
†††††††††††††††† Typically, we want to see this: roughly, a
†††††† ratio of 3:1.† In other words, the height of the
†††††† line has to be 3 times the depth of the crypt.
†††††† That is what typically we consider to be normal.
Despite the fact that they were on a
†††††† gluten-free diet, despite that, they fulfilled the
††† †††criteria.† They were gluten-free, symptom-free,
†††††† immunologically negative, and all the 9 yards.
†††††† They went on a one-month controlled diet.
†††††††††††††††† When we did the starting biopsy, there was
†††††† a slight decrease of the villus-crypt ratio,
†††††† meaning, the villi were a little bit shorter.† That
†††††† is what happens when you have an insult, the villi
†††††† become short and the crypts go deeper.
†††††††††††††††† The other parameter is the number of
†††††† CD3-positive cells, the intraepithelial lymphocytes
†††††† if you wish, was again 20 per hundred entrocytes
†††††† and controls and 30 in the celiacs on a gluten-free
†††††††††††††††† Therefore, at baseline already something
†††††† was going on.† It is like there is a status of
†††††† inflammation in which this is like a very
†††††† well-trained athlete, ready to react to anything if
†††††† it smells gluten coming through.† It is really at
†††††† the edge, ready to jump.
†††††††††††††††† There was a strong correlation between the
†††††† number of
intraepithelial lymphocytes and the
†††††† villus/crypt ratio, meaning, that the more healthy
†††††† is tissue, the less intraepithelial lymphocytes.
†††††† The healthier the tissue -- when the crypts are
†††††† elongated and the villa get short, the more
†††††† intraepithelial lymphocytes are there.† The
†††††† intraepithelial lymphocytes are really soldiers
†††††† that the immune system sensed at the forefront and
†††††† ready to fight the battle.† That is what it is.
†††††††††††††††† DR. FASANO:† Now, what kind of symptoms
†††††† after the three months these people experienced in
†††††† the three groups?† There were not really
†††††† significant differences: abdominal distention,
†††††† anemia, iron deficiency, loss of appetite,
†††††† bloating, and so on and so forth.
†††††††††††††††† There were equally distributed in all
†††††† groups including the placebo, but two really stand
†††††† out -- all in the 50 milligrams.† This stomatitis
†††††† and the mouth, there are the typical signs of
†††††† mucosal involvement of the oral cavity in celiacs,
†††††† well-described, it was present only in the
milligrams.† Weight loss was experienced
†††††† the 50 milligrams.† For the rest, we didn't see any
†††††† major differences.
†††††††††††††††† To revisit the concept that the antibodies
†††††† were useless -- these are the antibodies, IgA and
†††††† anti-tTG and IgG anti-gliadin antibodies -- before
†††††† and after the challenge in placebo 10 and 50
†††††† milligrams, there was no difference.† Pretty much
† †††††there was no difference among the groups.
†††††††††††††††† What we saw as the difference was the
†††††† villus/crypt ratio, that all in the 50 milligrams
†††††† started to decrease to a level of significance.
†††††† After three months, we saw the crypts become a
†††††† little bit deeper and the villi to become a little
†††††† bit shorter.† This translates in the fact that
†††††† there was damage that started to occur, or possibly
†††††† damage that started to occur.
†††††††††††††††† The intraepithelial lymphocytes, there are
†††††† these spots here (indicating).† Again, these are
†††††† lymphocytes under normal circumstances you see in a
†††††† smaller quantity in between epithelial cells.
†††††††††††††††† It came to be of a very increased number
†††††† in people
with 50 but not in 10, not reaching
†††††† statistical significance, but these are trends that
†††††† I have the obligation to report.† It is not
†††††† significant that there are more of these cells in
†††††† the 50 milligrams compared to the starting point,
†††††† but it is a trend there.
†††††††††††††††† DR. FASANO:† I believe the heart of all of
†††††† this is this table.† I believe this really cuts to
†††††† the chase.† It is extremely confusing, particularly
†††††† to patients, when you talk about milligrams and
†††††† parts per million.† What the heck are you talking
†††††† about?† Why do we use this parameter of parts per
†††††† million and not just straight milligrams?
†††††††††††††††† Because, by the way, say, you do the study
†††††† and you show that 50 milligrams could be dangerous,
†††††† so how can it be 10 milligrams?† How much is 10
†††††† milligrams?† How much of a pizza is 10 milligrams?
†††††† You say, "Well, let me give you the bad news.† It's
†††††† less than a fraction of a crumb of a piece of
†††††† bread.† That is what we're talking about.
†††††††††††††††† Still, it doesn't give you clearly what is
magnitude of the stuff that we are talking
†††††† about.† The reason why we prefer to express in part
†††††† per million rather than in milligrams is because
†††††† the amount that is tolerable really depends on how
†††††† much you eat.
†††††††††††††††† DR. FASANO:† As you see here, this is the
†††††† daily intake of gluten-free flour or whatever
†††††† products are based on gluten-free.† If you eat
†††††† 50 milligrams, of course you end up to ingest much
†††††† less than 300 milligrams of the substance that you
†††††† are eating.
†††††††††††††††† Let's say that, for example, we set the
†††††† parameter at 200 parts per million.† If we want to
†††††† accept the outcome of this study as something to
†††††† keep in mind, 10 milligrams is safe for everybody,
†††††† 50 milligrams start to be questionable.
†††††††††††††††† If you set the threshold at 200 parts per
†††††† million, if you eat a relatively small amount of
†††††† the stuff a day, you are okay.† If you eat a little
†††††† bit more, you are in an area that we don't quite
†††††† know, because again it is between 10 to 50
milligrams.† You can argue,
"Is 40 okay?† Is 30
†††††† okay?"† We don't know.
†††††††††††††††† Definitely, if you eat 300 grams a day --
†††††† in other words, you eat large amounts of
†††††† gluten-free products that is contaminated to the
†††††† level of 200 parts per million -- you start to go
†††††† into the red zone.† That is dangerous.
†††††††††††††††† If you go down this table, you see that if
†††††† you set 20 parts per million, no matter how much
†††††† your Italian lifestyle of eating like crazy food
†††††† that is gluten-free based, no matter how far you
†††††† go, you still are well below the threshold.
†††††††††††††††† Therefore, at least based on this study,
†††††† that I believe has been done really the way that it
†††††† is supposed to be done, long enough, because three
†††††† months is definitely a long period, a threshold of
†††††† 20 parts per million should be safe for the vast
†††††† majority of the people because it will keep you way
†††††† below the cutoff that seems to be dangerous, i.e.,
†††††† the 10 milligrams.
†††††††††††††††† DR. FASANO:† Now, this litany of names is
†††††† just to
explain that this was not a trivial study.†
†††††† It was a multicenter study that involved a
†††††† tremendous amount of work and a tremendous amount
†††††† of dedication of people that have no business to
†††††† undergo this, particularly two endoscopies with two
†††††† biopsies.† However, it is only because of the
†††††† dedication and the commitment of these people that
†††††† we have an answer and we have a chance to come to
†††††† you today with something that is a little bit less
†††††† foggy than so far we have had in terms of
†††††† prospective studies.
†††††††††††††††† I will stop there, and I will take any
†††††† questions that you have.
†††††††††††††††† CHAIRMAN DURST:† Thank you very much.
†††††††††††††††††††††† QUESTION AND ANSWER SESSION
†††††††††††††††† CHAIRMAN DURST:† Questions?
†††††††††††††††† DR. BRILEY:† Margaret Briley.† Can you
†††††† tell me, I didn't understand, how often did they do
†††††† the biopsies?† Every month?† Every three months?
††††† †††††††††††DR. FASANO:† No.† No, no, no, that would
†††††† kill us if we do it every month.† No, the biopsy
†††††† was done at
the beginning of the study, at the
†††††† entrance, and at the end of the study, three months
†††††† after, the idea being how much insult did you get
†††††† in two months.
†††††††††††††††† What was done at intermediate intervals
†††††† was a survey of the diet, to make sure that they
†††††† were complying with a gluten-free diet, survey
†††††† compliance of taking the pill, and the serological
†††††† tests for the antibodies.† Those were done on a
†††††† monthly basis.
†††††††††††††††† DR. BRILEY:† On a monthly basis?
†††††††††††††††† DR. FASANO:† That's right.
†††††††††††††††† DR. BRILEY:† Thank you.† That was good.
†††††††††††††††† CHAIRMAN DURST:† Erica.
†††††††††††††††† DR. BRITTAIN:† Erica Brittain.† If I'm
†††††† understanding correctly, the conclusion of the
†††††† study is that 10 milligrams daily would be safe,
†††††† was shown at least to be fairly similar to your
†††††† placebo group in this four-month exposure.† How
†††††† would you know how that would translate to four
†††††† decades of exposure?
†††††††††††††††† DR. FASANO:† Only with decades of
study.† You are a statistician, and you
†††††† know better than I do that you've got to start
†††††††††††††††† There is no question in my mind that the
†††††† only way to do that is like when you put a new drug
†††††† on the market, and you go to Phase I and you do 10
†††††† people.† When you do Phase II, you do 100 people.
†††††† You do Phase III, and 10,000 people.† Everything is
†††††† fine.† Ten years later, because millions of people
†††††† took it, it may be that something wrong will come
†††††† up, a classical example.
†††††††††††††††† I don't have an answer for you.† How do I
†††††† know in 10 years what's going to happen?† But, you
†††††† know, we have to have some way to start.† I believe
†††††† that this study is giving us a parameter, a
†††††† justification, a scientific rationale to say,
†††††† "Let's start here."
†††††††††††††††† CHAIRMAN DURST:† Okay.† Soheila.
†††††††††††††††† DR. MALEKI:† Soheila Maleki.† I was just
†††††† wondering, this is probably not directly related to
†††††† your topic, I heard earlier mention of wheat flour
†††††† and exposure.† How much is inhaled exposure
†††††† involved in
some of these reactions?
†††††††††††††††† DR. FASANO:† I don't think that anybody
†††††† can answer with scientific confidence that inhaling
†††††† is or is not a possible port of entry of gluten for
†††††† people with celiac disease to react to.
†††††††††††††††† What we know as a fact, an undisputable
†††††† fact, is that the intestine is the port of entry,
†††††† the key port of entry.† I can tell you anecdotally
†††††† that we have patients that react to inhalation of
†††††† gluten leading to asthma as an allergic reaction to
†††††† gluten rather than to celiac disease.
†††††††††††††††† How confident am I that this could be an
†††††† alternative to the other route?† I'm not really
†††††† confident, because I don't think that we have the
†††††† scientific proof beyond any reasonable doubt, as we
†††††† do with the other route, that it could be a
†††††††††††††††† DR. MALEKI:† Thank you.
††††††††††††† †††CHAIRMAN DURST:† Ciaran.
†††††††††††††††† DR. KELLY:† Yes.
†††††††††††††††† Thank you, Alessio, I agree.† Thank you
†††††† for sharing the data with us, and I agree that at
†††††† least it is
a basis that we can begin to work from
†††††† and make some rational approaches to what is best
†††††† for our patients with celiac disease.
†††††††††††††††† A couple of questions:† The first relates
†††††† to the earlier question about the 40-year
†††††† experiment.† There is one that there is a
†††††† 20 part-per-million threshold set already in Italy.
†††††† Could you comment on how well that is tolerated by
†††††† every or the vast majority of celiac patients in
††† †††††††††††††DR. FASANO:† Actually, it is much more
†††††† than that.† There are interesting natural
†††††† experiments being done.† Italy for many years now
†††††† reinforced the 20 parts per million.† England has
†††††† this 20 to a hundred, and so on and so forth.
†††††††††††††††† As far as I can tell you, this is
†††††† something that in Italy the food labeling
†††††† legislation setting it at 20 parts per million has
†††††† been there for 7 years.† It has been considered to
†††††† be absolutely safe with very sporadical reports of
†††††††††††††††† Now, I think it was telling you when you
†††††† have a
stomachache and you are a celiac, you tend
†††††† to go that way to the extreme that some people say,
†††††† "Today's ache is because I had gluten."
†††††††††††††††† I mean, this is the reality of the story.
†††††† But if you want to, statistically speaking, work on
†††††† the large numbers, I would say that 20 parts per
†††††† million has been proved to be safe.
†††††††††††††††† DR. KELLY:† In your study, then, and this
†††††† is something that we discussed a lot yesterday in
†††††† the context of food allergy and challenge studies,
†††††† is there the potential for bias in selection; in
†††††† other words, individuals who are highly sensitive,
†††††† in terms of symptomatically highly sensitive, to
†††††† low levels of gluten would either be afraid or not
†††††† choose to enter the study?
††† †††††††††††††DR. FASANO:† Absolutely.† Absolutely, no
†††††† question about it.† The reality of the story is
†††††† that if you are extremely sensitive to gluten, you
†††††† would be less willing to expose yourself to
†††††† something that you know is going to harm you.
†††††††††††††††† The point is, What percentage of the
†††††† population does that represent?† Is it 10 percent,
†††††† 20 percent,
50 percent, or a fraction of 1 percent
†††††† of the celiac population?
†††††††††††††††† You know, I'm pretty sure everybody that
†††††† is involved in the clinical care of people with
†††††† celiac disease has run into people who are
†††††† extremely, extremely sensitive to gluten out there.
†††††† The exception are people where actually the problem
†††††† is the opposite; these are people who can eat
†††††† dangerous amounts of gluten and they do not react.
†††††† That is a problem.
†††††††††††††††† CHAIRMAN DURST:† Dick Durst.† Just to
†††††† follow up on that, How did you recruit the people
†††††† for these studies?
†††††††††††††††† DR. FASANO:† The method of recruitment is
†††††† a major advantage of the Italian setting is that
†††††† there is a single Celiac Society, and they are
†††††† extremely committed.† What we did was very simple.
†††††† They have a national bulletin, both electronically
†††††† and on paper, that is read pretty much by the vast
†††††† majority of the members of the celiac community.
††††††††† †††††††I believe that we originally asked for 45
†††††† volunteers.† That is the number that the
biostatistician told us to go for to have a
†††††† meaningful outcome.† We got 470 volunteers, so we
†††††† had to turn people down.
†††††††††††††††† CHAIRMAN DURST:† Did you at that point
†††††† know which ones were the hypersensitive or the more
†††††† sensitive versus other and select on that basis at
†††††††††† ††††††DR. FASANO:† No.† The way that these
†††††† people were selected was completely random.† In
†††††† other words, the least that we had every "X," three
†††††† or four up -- I don't know, to make the number --
†††††† were called to make that unbiased.† We really
†††††† wanted a representative portion of the population.
†††††† This was done by also sex and age.
†††††††††††††††† DR. KELLY:† Ciaran Kelly again.† I do have
†††††† one other question, and it has to do with the
†††††† interpretation of the data on villus/crypt ratio
†††††† and IEL counts in the controls versus the
†††††† well-controlled celiacs.
†††††††††††††††† You showed that there was a small
†††††† difference at baseline, even though those
were doing well on a gluten-free diet.†
†††††† Your interpretation is that there is an underlying
†††††† immune activation.† My question is, Is it possible
†††††† or likely or relevant that the 20 parts per million
†††††† that they are taking is perpetuating that?
†††††††††††††††† DR. FASANO:† What I am trying to convey is
†††††† the difference is that the recovery -- even if you
†††††† are completely, religiously gluten-free -- is not
†††††† 100 percent.† That is what I meant.
†††††††††††††††† I don't know if this is due to an ongoing
†††††† immune response.† I believe that to not probably be
†††††† the case.† Because after all, after all with all of
†††††† the machinery in the community, these people have
†††††† been proved not to go back to normal.† Whereas,
†††††† again, the fact is that no matter how you push it,
†††††† you can't really go back to normal.
†††††††††††††††† I think that the fact that for three
†††† ††months, even if you were really "touched," so to
†††††† speak, you did not react to 10 milligrams.† For me
†††††† it was a great level of confidence that this is the
†††††† way to go -- together again with data with a
†††††† retrospective study, that we are going to hear
†††††† about in a
moment, and on-the-field exercise in
†††††††††††††††† CHAIRMAN DURST:† Jean?
†††††††††††††††† MS. HALLORAN:†† Another question about the
†††††† sample group.† When you did the baseline study, how
†††††† much variability did you find in the members of
†††††† that group?
†††††††††††††††† DR. FASANO:† Let me see if I can go back
†††††† on this.
†††††††††††††††† MS. HALLORAN:†† You had two factors that
†††††† you looked at, the villus height --
†††††††††††††††† DR. FASANO:† Can you put on the slide show
†††††† for a second?
†††††††††††††††† (Ms. Sylvia Smith complies.)
†††††††††††††††† DR. FASANO:† You will see that there was
†††††††††††††††† MS. HALLORAN:†† Slide 32.
†††††††††††††††† DR. FASANO:† Can you bring me over there,
†††††††††††††††† DR. FASANO:† There is a fair amount of
†††††† variability.† You see that, and there is some
†††††††††††††††† If you go down -- keep going -- now, if
†††††† you can go up to 28, please?
††††††††††††††† †MS. HALLORAN:† It is 32, I think.
†††††††††††††††† DR. FASANO:† You want 32?† I thought that
†††††† you were talking about the variability of the
†††††† villus/crypt ratio.† Is that what you are talking
†††††††††††††††† CHAIRMAN DURST: †Yes.
†††††††††††††††† MS. HALLORAN:† Yes.
†††††††††††††††† DR. FASANO:† It is a little bit higher
†††††† than that.
†††††††††††††††† Can you go higher?
†††††††††††††††† MS. HALLORAN:† Ah.
†††††††††††††††† DR. FASANO:† Stop here.† I need 26.
†††††††††††††††† DR. FASANO:† All right.† You see here,
†††††† this is the variability.† You see here that this is
†††††† the variability.† These are the single points.† If
†††††† there was somebody that was high right here
†††††† (indicating), and someone like here, these are the
celiacs.† There was a continuum,
so it is not that
†††††† there are people here, people there; it is a
††† †††††††††††††This is the standard deviation, and this
†††††† is the mean.† Again, there is some variability but
†††††† not huge.† There is much more variability in the
†††††† intraepithelial lymphocytes -- you can see this
†††††† scatter -- that are being monitored.
†††††††††††††††† CHAIRMAN DURST:† Suzanne.
†††††††††††††††† DR. TEUBER:† Suzanne Teuber.† I would
†††††† assume, and this may be a completely incorrect
†††††† assumption, that in the population that is
†††††† following a gluten-free diet strictly, as those you
†††††† indicated you recruited, would actually be a subset
†††††† of patients who perceive themselves to be very
†††††† sensitive, and thus would have a higher motivation
†††††† to follow such a diet.
†††††††††††††††† This would bring up in Italy what percent
†††††† of patients do comply with the gluten-free diet?
†††††† We heard about the extreme difficulties here and
†††††† the poor compliance rate.† Is it better in Italy?
†††††† Would this mean that, perhaps, this population that
recruited from really might be a good sensitive
†††††††††††††††† DR. FASANO:† I think, and I'm paraphrasing
†††††† Joe Murray on this, that the compliance with the
†††††† diet is the results of many factors, some of them
†††††† diet there.† Education I believe is at the top of
†††††††††††††††† It is not that you feel it to be more
†††††† sensitive or less sensitive.† If you understand the
†††††† facts, if you understand the rules of the game, no
†††††† matter how you are perceived as being sensitive or
†††††† not sensitive, you know that you can't cheat.† You
†††††† know that you need to start with that.
†††††††††††††††† If you go to 10 doctors and they say all
†††††† the same things, "I'm sorry, you don't have an
†††††† alternative," then the level of confidence
†††††† increases.† We don't have that here.† We don't have
†††††† it, honestly.
†††††††††††††††† Let's be honest.† We have people, doctors,
†††††† that will tell you, "You know, you need to go on a
†††††† gluten-free diet."† These are the teaching sheets
†††††† that were printed 20 years ago.† "After three
†††††† months, go
back on a regular diet.† You're going to
†††††† grow out of it."† What level of confidence do you
†††††††††††††††† Definitely, a study like here, like this
†††††† done here, will have a tremendous amount of bias.
†††††† Because who is going to do that?† It will be only
†††††† the ones that are extremely compliant.† The
†††††† population in Italy that is compliant -- in Italy?
†††††††††††††††† I should not say in Italy, in Europe --
†††††† because they are like 10 or 15 years ahead of us in
†††††† this, because the level of awareness has been there
†††††† for quite a long time -- is pretty high.
†††††††††††††††† They understand exactly what is at risk.
†††††† That is the reality of the story.† It is more than
†††††† to be the people with high cholesterol, high blood
†††††† pressure and to be on medication because there is
†††††† much more flexibility there.
†††††††††††††††† These people they understand that if they
†††††† don't comply the pay a price, and they do.† The
†††††† level of frustration, particularly here, is that
†††††† they want to do that, the ones that understand the
†††††† game, but they can't because there is no way in
current situation they can comply.
†††††††††††††††† CHAIRMAN DURST:† Doug.
†††††††††††††††† DR. HEIMBURGER:† Doug Heimburger.† Would
†††††† you go to the next slide, please, after this one?
†††††††††††††††† DR. FASANO:† Sure.
†††††††††††††††† DR. HEIMBURGER:† Does this graph include
†††††† the controls or only celiac patients?
†††††††††††††††† DR. FASANO:† These are only the celiacs.
†††††††††††††††† DR. HEIMBURGER:† Just out of interest, did
††† †††you test for this correlation in the controls?
†††††††††††††††† DR. FASANO:† Yes, it is the same.† We put
†††††† it all together, yes.† There is a strong
†††††† correlation.† Again, if you conceptualize this
†††††† intraepithelial lymphocytes as, again, the first
†††††† folks to go there -- just two weeks ago, for
†††††† example, there was a paper in science in which they
†††††† claimed that the lymphocytes, they are called
†††††† gamma/delta, they are able to present antigens.
†††††††††††††††† They can see gluten and they can start the
†††††† entire reaction, at least to the adaptive immunity
†††††† Th2 response to interferon-gamma, that will
in damage, i.e., to make the villi short
†††††† and the crypt deeper.† That makes a lot of sense.
†††††† The more you have, the more cytokines you can use,
†††††† the more damage you have.
†††††††††††††††† CHAIRMAN DURST:† Dr. Fasano, will you be
†††††† around for the discussion this afternoon?
†††††††††††††††† DR. FASANO:† Yes.† Yes, I will.
†††††††††††††††† CHAIRMAN DURST:† Because I think maybe we
†††††† will stop the questions.
†††††††††††††††† DR. FASANO:† I have my candy so I can't
†††††† leave you.
††† †††††††††††††(General laughter.)
†††††††††††††††† CHAIRMAN DURST:† Okay.† We will probably
†††††† move on so we don't go too far into the lunch hour.
†††††††††††††††† Our next speaker is Dr. Pekka Collin.† He
†††††† is a professor at the University of Tampere Medical
†††††† School in Finland.† He will discuss retrospective
††††††††††††††††††††††††† RETROSPECTIVE STUDIES
†††††††††††††††† DR. COLLIN:† Yes, good morning everyone.
†††††† I come from Tampere.† You probably know where
† †††††Finland is and Tampere is a hundred miles north of
†††††††††††††††† DR. COLLIN:† We at least in Tampere think
†††††† that is the celiac center of Finland, but maybe
†††††† somebody disagrees with that.† We have a half a
†††††† million people around our hospital and now our
†††††† clinical prevalence of celiac disease is
†††††† approaching 1 percent.† I think it is .7 at the
†††††† moment, so we have 1,000 patients with celiac
†††††† disease.† Consequently, we have tried to examine
†††††† both the symptoms and the diet.
†††††††††††††††† DR. COLLIN:† I had some specific issues
†††††† which I should address at this meeting, and they
†††††† are here.† I should explain why we carried out our
†††††† retrospective analysis of the gluten content in our
†††††† gluten-free products; then, also, calculate what is
†††††† the significance of daily gluten exposure in this
†††††† small amount of gluten; and then, also, to discuss
†††††† is there some variability in the sensitivity of
†††††† people with gluten intolerance which has been
†††††† discussed here already many times.† That should
include patients who are taking with
†††††† starch-based, gluten-free products and who are
†††††† taking oats where we have a lot of experience.
††††† †††††††††††DR. COLLIN:† I think that celiac disease
†††††† has been described very well by previous speakers,
†††††† so I will go straight into the point.† However, I
†††††† will emphasize that now we are talking about parts
†††††† per million or 10 milligrams or 20 milligrams of
†††††† gluten intake.
†††††††††††††††† DR. COLLIN:† In real life, if you have 100
†††††† patients with celiac disease, I think 90 percent of
†††††† them are taking 15 grams of gluten a day because
†††††† they do not know that they have celiac disease.
†††††††††††††††† Only 10 out of 100, for instance, in the
†††††† U.S.A. I think know that they suffer from celiac
†††††† disease.† Of the remainder 10, maybe 3 or 4 do not
†††††† follow a gluten-free diet strictly because they
†††††† don't care, or it is more likely because there are
†††††† not enough products when they are eating out or
†††††† eating in restaurants, and so on.
think that is very important, that we
†††††† have a good choice of products.† That is more
†††††† important than some parts per million in order to
†††††† achieve a good percentage of compliance.
†††††††††††††††† The amount of threshold, I think it
†††††† started more than 10 years ago in Europe.† The
†††††† celiac societies were very, very active in these
†††††† respects.† From southern countries, some people say
†††††† that we are in northern countries poisoning our
†††††† people because they know that we are giving them
†††††† wheat-starch-based, gluten-free products.
†††††††††††††††† On the other hand, our society, I think
†††††† they are very -- I don't find the right word -- but
†††††† I admire them because they said, "Please make the
†††††† study.† Look at what we are now eating.† Celiac
†††††† patients are the last who will have some extra,
†††††† unnecessary dietary restrictions, so please make a
†††††† study where you show whether we are now eating
†††††† safely or not."† I think that was the background
†††††† for our so-called "retrospective study."
†††††††††††††††† At that time we were quite relaxed.† We
†††††† were not afraid that we are poisoning our people,
†††††† because we
published a study where we showed that
†††††† in our patients we did not have, in treating
†††††† patients we did not have, any extra mortality and
†††††† even we did not have any extra risk of malignant
†† ††††conditions at that time.
†††††††††††††††† Then, we looked at what the Finnish
†††††† celiacs are eating.† As expected, the majority of
†††††† them took wheat-starch-based, gluten-free products.
†††††††††††††††† We can also see that compliance was very
†††††† good.† These patients they were invited, after 5 or
†††††† 10 years on a gluten-free diet they were invited, a
†††††† cohort of those patients, both so-called
†††††† "sensitive" and not sensitive, and we can see that
†††††† only a small percentage of patients had dietary
†††††† transgressions.† Although there were a few who
†††††† daily or twice a week or once a month had dietary
†††††† lapses, most people preferred to follow a naturally
†††††† gluten-free diet.
†††††††††††††††† We also show that for these patients their
†††††† quality of life is good, and they did not have any
†††††† additional symptoms compared to the population.† As
†††††† has been
mentioned many times earlier, symptom is
†††††† not a very reliable objective sign of gluten
†††††††††††††††† DR. COLLIN:† This is an example how
†††††† symptoms can be misleading.† This is maybe a little
†††††† bit out of the topic, but I think this is very
†††††††††††††††† We ask family doctors to send us all such
†††††† patients who spontaneously reported that they get
†††††† symptoms after taking wheat or rye.† The majority
†††††† of them had also on their own account tried to
†††††† avoid or withdraw these products from their diets,
†††††† and they experienced clear improvement in symptoms.
†††††††††††††††† We thought that many of them had latent or
†††††† overt celiac disease, but to our surprise only 10
†††††† percent of people with a clear history of
†††††† intolerance to gluten had really celiac disease.
†††††† Then, there are some which we thought that they
†††††† maybe had wheat allergy.
†††††††††††† ††††When I was here yesterday I heard about
†††††† that.† Yes, the diagnosis is so difficult, so I
†††††† hope that I
don't have to discuss this in more
††††††††††††† †††However, the majority of them, even with
†††††† sophisticated methods, they did not have any signs
†††††† of celiac disease and probably they have irritable
†††††† bowel syndrome.† Hence, we cannot trust symptoms
†††††† even in the diagnosis of celiac disease.
†††††††††††††††† DR. COLLIN:† Then, of course we have to go
†††††† to small bowel biopsy as they did also earlier.† We
†††††† took a control biopsy after 5 to 10 years from
†††††† these patients who had been diagnosed with celiac
†††††† disease and who were asked to come to our hospital.
†††††††††††††††† DR. COLLIN:† What we can see here is that
†††††† this is the same villous height/crypt depth ratio
†††††† which has been measured by, for instance,
†††††† Alessio Fasano.† Here is our reference value for
†††††† people who have no suspicion of celiac disease.
†††††† They have come to endoscopy because of suspected
†††††† some gastrointestinal disorder, reflux symptoms or
We can see that in our long-term treated
†††††† patients, there is a 95 confidence interval, so it
†††††† was exactly the same as in our non-celiac people.
†††††† I could show also a similar slide of
†††††† intraepithelial lymphocytes, very similar.† They
†††††† did not have extra intraepithelial lymphocytes.
†††††††††††††††† We did not either have any so-called
†††††† "highly sensitive" patients with celiac disease.
†††††† We had some here who had not a complete recovery in
†††††† the mucosa.
†††††††††††††††† After dietary inspection, it turned out
†††††† that all of these people are taking occasionally
†††††† gluten.† Even once a month, I think that was in the
†††††† data, the histological recovery was not complete
†††††† Then, we had also here are the celiac patients
†††††† where the ratio was of course low.
†††††††††††††††† Then, we had some short-term treated
†††††† patients, that means from half year to one year.
†††††† We show that the healing was not complete at that
†††††† time.† From this slide we had two questions.
†††††††††††††††† First, when we have a complete recovery,
†††††† are those patients still taking some small amounts
††† †††of gluten or are their products complete
†††††††††††††††† The second question was, When we have this
†††††† incomplete recovery, does it depend on wheat starch
†††††† or gluten contamination or is it normal life in
†††††† celiac disease?† In other words, would the healing
†††††† be better if instead of wheat starch used, the use
†††††† of naturally gluten-free products?
†††††††††††††††† To the first issue, Are those products
†††††† contaminated which have shown that our people are
†††††† doing well and their mucosal is healthy?† It was
†††††† not surprising that most of naturally gluten-free
†††††† products had less than 10 ppm gluten.
†††††††††††††††† However, I think it is very important to
†††††† realize that some of the so-called naturally
†††††† gluten-free products, they may be contaminated with
†††††† gluten, even quite high.† All of these were
†††††† fulfilling the current European Codex standard.
†††††††††††††††† If we go to the wheat-starch-based,
†††††† gluten-free flours, there were two with zero
†††††† gluten, and as expected most of them contained
†††††† trace amounts of gluten.† Two had more than 100,
†††††† but the
majority has less than 100.† That was
†††††† idea that maybe we can set the limit to 100 ppm.
†††††††††††††††† When I had this slide and my conclusion in
†††††† Europe, one of the representatives of industry said
†††††† that he was disappointed because I am talking about
†††††† 100 ppm, and I should have talked about the limit
†††††† of 200 ppm because it is much easier for them.
†††††††††††††††† However, I said that we had too few
†††††† products here to assert that 200 ppm would be
†††††† recommendable.† I think I will remind you that
†††††† 90 percent of our celiacs have used this product
†††††† for 40 years or even more, and we have
†††††† biopsy-proven results from that so-called challenge
†††††† from 5 to 10 years.† The mucosal recovery, as I
†††††† said, was perfect.
†††††††††††††††† DR. COLLIN:† We also looked at how much
†††††† they did use those flours.† Maybe somebody who has
†††††† taken gluten-free products can know that they are
†††††† not necessarily as good as wheat, baking with
†††††††††††††††† Nevertheless, here are how the patients
†††††† used these
products.† There was no difference
†††††† between wheat-starch-based products or a naturally
†††††† gluten-free diet.† The average was 80 grams, and
†††††† the majority took less than 150 grams as you can
†††††† see here.† There was no correlation between the
†††††† villus damage and the amount of data used of loss.
†††††††††††††††† DR. COLLIN:† From here we come to this
†††††† conclusion, which maybe you have seen this kind of
†††††† table in Alessio Fasano's presentation.† Provided
†††††† that we set the limit to 100 ppm, and provided that
†††††† each of these products also contained the maximum
†††††† amount allowed, when patients are taking 100 grams
†††††† of those or 200 grams of those the gluten
†††††† contamination is from 10 to 20 milligrams.
†††††††††††††††† If you look at Fasano's results and if you
†††††† look at some earlier, small studies -- even the
†††††† Catassi study, which was referred to, and some
†††††† smaller studies made by Sturgis and so on -- I
†††††† think we are very, very safe here at the 100 ppm.
†††††† I think also that our clinical experience will show
†††††† that the same.
Of course, this is not a prospective
†††††† study, and we did not have any control group, and,
†††††† unfortunately, we did not have many patients who
†††††† have clear dietary restrictions, so we cannot make
†††††† any statistical analogies between those who are --
†††††† what is the word -- cheating with their diet and
†††††† who are not.† However, I think with this kind of
†††††† system, we can treat our patients and have good
†††††††††††††††† DR. COLLIN:† If I can, go to the issue
†††††† whether patients are more sensitive or
†††††† hypersensitive patients with celiac disease.† When
†††††† we look at those patients, we can see that their
†††††† mucosal recovery takes place in a different way in
†††††† different people.† That has been very well shown in
†††††† some challenge studies.† Where earlier it was
†††††† customary to accept diagnosis, we have once again
†††††† to challenge the patients to gluten-free diets and
†††††† look at if there will emerge new villus atrophy.
†††††††††††††††† We show that in some cases it took two
†††††† months or one month to see a mucosal relapse, but
†††††† in some
cases it took two or three years.† Our
†††††† record is 15 years.† Fifteen years with normal diet
†††††† and earlier diagnosed celiac disease, after 15
†††††† years a mucosal relapse occurred.
†††††††††††††††† Here we can see that in the short-term
†††††† some people do not respond, and you could think
†††††† that these might be so-called "hypersensitive."† If
†††††† we give enough time and the patients are truly
†††††† following the gluten-free diet, which means that we
†††††† must be really accurate that they do not take wheat
†††††† at the same time, I think in the long-term we have
†††††† almost complete recovery.† We did not have any
†††††† so-called "hypersensitive."
†††††††††††††††† I think patients with refractory sprue
†††††† they can be very sensitive because they do not
†††††† respond at all to celiac disease, but that is a
†††††† different issue.† It is probable that even zero
†††††† gluten would not help them.† There is something
†††††† wrong in their gut.† Probably the diagnosis has
†††††† been made too late, and it does not recover any
†††††† more.† I think that refractory sprue is outside of
†††††† the topic of this day.
Also, we were discussing with Peter Chen,
†††††† when he wrote to "Gastrointestinal Endoscopy" that
†††††† complete mucosal recovery is not possible, and we
†††††† had a very friendly, friendly discussion in the
†††††† pages of that journal.† However, we said that it is
†††††† possible when we have a good choice of products and
†††††† people also outside the home know what celiac
†††††† disease is what this means for the patient with a
†††††† gluten-free diet.
†††††††††††††††† The second issue in my slide was that
†††††† could it be that the mucosal healing would be more
†††††† rapid in those who are on a naturally gluten-free
†††††† diet than in those who are maintaining
†††††† wheat-starch-based, gluten-free products?
†††††††††††††††† Here, we carried out a randomized
†††††† prospective study of one year in newly detected
†††††† celiac disease patients.† If we look at the villus
†††††† healing here and here, villous height/crypt depth
†††††† ratio, there were no differences between these two
†††††† groups.† We can also see that in one year, you
†††††† cannot achieve the limit of three, which is
†††††† considered normal.
Similarly, when we look at intraepithelial
†††††† lymphocytes, they decreased in a similar way in
†††††† both patients.† At that time, unfortunately, we
†††††† could not measure what was the exact amount of
†††††† gluten these patients were taking; we did not have
†††††† methods.† We can assume they took those same
†††††† products which were mentioned in my last slide
†††††† which contained trace amounts of gluten but not
†††††† more than 100 ppm.
†††††††††††††††† DR. COLLIN:† If I may say some words about
†††††† oats.† It was in Finland, the first publication.
†† ††††After that, very soon it was accepted for celiacs
†††††† in Finland that they may use oats.† At the
†††††† beginning we were very careful.† We followed up
†††††† with them each month and looked at what to do, but
†††††† now we do not do it anymore.
†††††††††††††††† We made a question out, too.† We sent a
†††††† question out to members of the Celiac Society, how
†††††† do they appreciate oats.† As you can see, they like
†††††† about the permission to eat oats.
†††††††††††††††† Almost all said that it is a very
part of every day gluten-free diet in
†††††† terms of tasty and low lost.† They even thought
†††††† that it is healthy, diversifies the diet, and we
†††††† have a good availability in Finland of oat
†††††† products.† I understand that maybe in some
†††††† countries oat is not so important.
†††††††††††††††† Some might say that in Finland they are
†††††† not eating good, so maybe people in Italy do not
†††††† operate yet in the same manner as in Finland, but
†††††† we can discuss it.
†††††††††††††††† DR. COLLIN:† Here are how our people have
†††††† now used oats, the majority of patients -- not
†††††† great amounts, it is only 20 grams, 15 or 20 grams.
†††††† There, most of the studies are about approximately
†††††† 50 grams, so less than in those randomized studies.
†††††††††††††††† Some people do not prefer oats, and that
†††††† is the same thing in people in general not only in
†††††† celiac patients.† Some of them had stopped, and the
†††††† reason is that they had developed symptoms.† Some
†††††† even got a rash, basically dermatitis
†††††† herpetiformis.† We do not have any proof that the
†††††† reason for
stopping would be that they
†††††† simultaneously had mucosal damage.† Usually, the
†††††† mucosa is good even though the patient has stopped
†††††† the diet.
†††††††††††††††† The rest, in dermatitis herpetiformis, we
†††††† also saw that even in patients with no oat diet, so
†††††† even they may have a temporary rash.† There are
†††††† some clinical relapses in patients with dermatitis
†††††† herpetiformis also.
††††††††††††† †††It is excellent to study these questions,
†††††† because we can change the subjective symptoms quite
†††††† rapidly to objective science, count the number of
†††††† blisters, for instance.
†††††††††††††††† DR. COLLIN:† We also looked at the quality
†††††† of life in patients with oats.† Actually, there was
†††††† no change, difference, compared to patients with no
†††††† oats.† This also was a prospective, randomized
†††††† study in treating celiac disease.
†††††††††† ††††††Interestingly, those patients who were
†††††† taking oats, they reported more symptoms of
†††††† diarrhea, which was statistically significant.
†††††† They also
reported more constipation, which was not
†††††† significant.† Even in these patients, we did not
†††††† have any mucosal deterioration.
†††††††††††††††† From this we learned that if we start on a
†††††† gluten-free diet with oats, we must inform the
†††††† patient that "You may have symptoms after this.† If
†††††† you have symptoms, why continue.† But it is
†††††† improbable that we have done any harm to your
†††††† small-bowel mucosa.
†††††††††††††††† We also saw that those who were taking
†††††† oats had a little bit more intraepithelial
†††††† lymphocytes, not CD3 lymphocytes, which we have
†††††† discussed today, but gamma/delta lymphocytes.
†††††††††††††††† The gamma/delta lymphocytes were a little
†††††† bit increased in the oat group.† I cannot explain
†††††† the reason for that, and that has not been
†††††† published elsewhere -- but that is the fact.
†††††††††††††††† DR. COLLIN:† Here are my conclusions to
†††††† the questions which I was asked to answer.† Maybe I
†††† ††also specific questions which you have, specific
†††††† issues which you have to address in the final
†††††††††††††††† If I may say something about the
†††††† subpopulation, the most highly sensitive people, I
†††††† think such people of course may be, but eventually
†††††† they have good mucosal recovery, provided that they
†††††† follow a gluten-free diet.† The majority of these
†††††† highly sensitive patients are probably such people
†††††† who have advertent or inadvertent gluten intake.
†††††††††††††††† We can also remember that even if it
†††††† happens, the consequences are not disastrous,
†††††† because they do not develop an anaphylaxis aspect
††††† †as do people with peanut allergy as we heard today.
†††††††††††††††† We can quite easily detect these highly
†††††† sensitive, if we after the diagnosis, one year
†††††† after the diagnosis, take a small-bowel biopsy and
†††††† look at whether there is an improvement in the
†††††† mucosal architecture.† If there is not, we must
†††††† consider that they may be very sensitive, but
†††††† usually they do not follow the gluten-free diet.
†††††††††††††††† About the risk of malignant diseases, I
††††† †think the whole literature tells that those people
†††††† who are at an increase risk of malignant lymphoma,
diagnosis has been made too late.† They
†††††† already have lymphoma when the symptoms of celiac
†††††† disease appear and when they get the diagnosis of
†††††† celiac disease, or they have had dietary
†††††† transgressions for a prolonged time.
†††††††††††††††† Of over 1,000 patients I have seen during
††††† †the 15 years, I have seen one patient who has
†††††† developed lymphoma after being 5 or 10 years on an
†††††† apparently gluten-free diet.† The risk of these
†††††† severe complications in those small daily intake is
†††††† probably very low.† Even our new data show the
†††††† same, which is now published only in abstract.
†††††††††††††††† Similarly, the mortality, it depends on
†††††† those patients who come to the hospital together
†††††† with the diagnosis of celiac disease and later,
†††††† usually within six months, we can see that they
†††††† also have lymphoma.
†††††††††††††††† DR. COLLIN:† What about the oats?† Here I
†††††† summarized some studies.† Those with plus signs
†††††† they are those who have shown that oats have no
†††††† adverse effect on the mucosa.† I think nearly
†††††† almost all
of these studies are randomized,
†††††† open-randomized.† They have a control group with
††† †††non-oat.† We have hundred of patients who seem to
†††††† tolerate oats.
†††††††††††††††† But I think I would be stupid if I did not
†††††† see also those two papers and patients who are
†††††† sensitive.† I cannot close my eyes from the
†††††† results, because Don Kasarda told the data very
†††††††††††††††† I don't know who they are.† Maybe there
†††††† are some who really develop villus atrophy after
†††††† taking oats, but that must be an extremely rare
†††††† condition. †Because, as you see, we have so many,
†††††† many patients who are taking oats, and we have not
†††††† seen this phenomenon.
†††††††††††††††† Still, we must be careful, and we must be
†††††† careful because patients with oats may develop
†††††† symptoms.† If everything does not go well, of
†††††† course we stop the use of oats.† However, we must
†††††† be aware of that, that maybe there are some rare
†††††† patients where it acts the same as gliadin for most
†††††† people with celiac disease.
†† ††††††††††††††I don't know whether these, my
†††††† recommendations, can be applied in the United
†††††† States but that is how we are doing now.† Our
†††††† celiac society is very happy because we said that
†††††† you can continue with starch-based, gluten-free
†††††††††††††††† Thank you very much.
†††††††††††††††† CHAIRMAN DURST:† Thank you.
†††††††††††††††††††††† QUESTION AND ANSWER SESSION
†††††† ††††††††††CHAIRMAN DURST:† Do we have questions?
†††††††††††††††† DR. TEUBER:† Suzanne Teuber.† My question
†††††† relates to the applicability of the diet parameters
†††††† to the United States dealing with how much
†††††† gluten-free flour do people in different parts of
†††††† the world ingest, if they were to have the option
†††††† of knowing that something was truly, truly
†††††††††††††††† You talk about 100 parts per million.† It
†††††† was your data that came up with the 80 grams a day
†††††† that people ingest.† I'm wondering -- you know, we
†††††† are not setting any level here today -- in terms of
States' folks, I have no idea how that would
†††††† apply.† Would this be a safe level for them?† Or,
†††††† here, would people be preferring to adjust much
†††††† more?† Do you have any input on that?
†††††††††††††††† DR. COLLIN:† I think there is not much
†† ††††data on that, how much people really in different
†††††† parts of the world are really using wheat or other
†††††† flours which may be harmful to patients with celiac
†††††††††††††††† I think that this is a subject for further
††† †††studies.† Maybe somebody here knows how much celiac
†††††† patients are here using gluten-free flours, but I
†††††† don't know.† I have not seen any publications about
†††††† this issue.
†††††††††††††††† CHAIRMAN DURST:† Any other questions?
††††† †††††††††††DR. McBRIDE:† Margaret McBride.† Did I
†††††† understand correctly that gluten-free in Finland
†††††† means 100 part per million?
†††††††††††††††† I guess for me, as I'm thinking about it,
†††††† maybe part of the difference between the two
†††††† studies, aside from the obvious
†††††† retrospective/prospective, et cetera, is that in
†††††† Italy the
gluten-free diet did contain some,
†††††† although very little at 20 parts per million
†††††† gluten, in addition to what was administered.
†††††††††††††††† I don't know if there is an estimation of
†††††† how much that would be.† I'm also thinking maybe
†††††† there is more interest in pasta in Southern Europe
†††††† than in Northern Europe.
†††††††††††††††† DR. COLLIN:† I think that today we have
†††††† given the formal Codex standard which says that
†††††† 200 ppm is okay, but of course we need to
†††††† reconsider that.
†††††††††††††††† I think that in the whole of Europe there
†††††† will be two limits, that is the 20 milligram which
†††††† can be used in the highly sensitive people, but in
†††††† the majority of people it is 100 ppm.
†††††††††††††††† Of course, there is a problem with
†††††† labeling, how we should label that.† We cannot say
†††††† that it is "low gluten," because then people will
†††††† use that.† That is our problem.
†††††††††††††††† What our recommendation is, is that maybe
†††††† the majority of people with celiac disease can
†††† ††tolerate products which are under the limit of
†††††† 100 ppm.
†††††††††††††††† DR. KELLY:† Ciaran Kelly.† I wonder in
†††††† terms of compliance with the diet and acceptance of
† †††††the diet, is there a big difference between 20
†††††† parts per million or 100 parts per million from the
†††††† perspective of the palatability of the food?
†††††††††††††††† DR. COLLIN:† I think the important thing
†††††† is, at least the industry in Europe says, that, if
†††††† we go to very low level, there are not so many
†††††† alternatives for gluten-free products, which again
†††††† may result in that general compliance will be worse
†††††† than I have shown now.
†††††††††††††††† How the products, how they--?† I think
†††††† that those wheat-starch products, I think they are
†††††† very tasteful.† Does it depend on the small
†††††† milligrams of gluten or not?† I don't know.† But,
†††††† as can be seen, most of the people are preferring
†††††† those products instead of naturally gluten-free.
†††††††††††††††† CHAIRMAN DURST:† Anyone else?
†††††††††††††††† (No verbal response.)
†††††††††††††††† CHAIRMAN DURST:† If not, thank you,
†††††† Dr. Collin.
Our final speaker for this morning is
†††††† Rhonda R. Kane from the Consumer Safety Office of
†††††† CFSAN, FDA, on international perspectives on
††††††††††††††† INTERNATIONAL PERSPECTIVES ON GLUTEN-FREE
†††††††††††††††† MS. KANE:† Good afternoon.† My name is
†††††† Rhonda Kane.† I am with the Food and Drug
†††††† Administration, and I was asked to present
†††††† information to the Food Advisory Committee about
†††††† how the term "gluten-free" is defined in other
†††††† countries and the basis for those definitions.
†††††††††††††††† MS. KANE:† My presentation today will
†††††† focus on four examples of international or national
†††††† definitions of the term "gluten-free" that apply to
†††††† labeled packaged foods.
†††††††††††††††† The first two examples I will be
†††††† discussing pertain to Codex Alimentarius and they
†††††† include, the first one, Codex Standard 118-1981,
†††††† which pertains to the Codex standard for
†††††† gluten-free foods that was established in 1981, was
†††††† amended in 1983 and is in effect today; and, two,
Proposed Draft Revised Standard for Gluten-Free
†††††† Foods at Step 7 that is now under consideration by
†††††† the Codex Committee on Nutrition and Foods for
†††††† Special Dietary Uses as a replacement for the
†††††† current standard.
†††††††††††††††† For ease in my presentation, I am going to
†††††† refer the Codex Committee on Nutrition and Foods
†††††† for Special Dietary Uses simply as the "Codex
†††††† Nutrition Committee."
†††††††††††††††† In the early 1990s, members of the Codex
†††††† Nutrition Committee agreed that developments in the
†††††† characterization of gluten on studies on gluten
†††††† tolerance warranted a revisiting of the current
†††††† standard and an updating of it.
†††††††††††††††† The current proposed standard has
†††††† undergone several revisions and is now at Step 7 of
†††††† an 8-step process pending resolution of certain
†††††† issues including what method of detection is going
†††††† to be used for gluten and the results of gluten
†††††† threshold studies in celiac patients.† The Codex
†††††† Nutrition Committee will be meeting in November
†††††† 2005, and will be discussing the proposed standard.
The third example of gluten-free that I
†††††† will be discussing is found in Canada's Food and
†††††† Drug Regulations at Section B.24.018.† It became
†††††† effective on May 1, 1996.
†††††††††††††††† Lastly, I will review the definitions of
†††††† both "gluten-free" and "low-gluten" that are found
†††††† in Clause 16 of Standard 1.2.8 of the Australia
†††††† New Zealand Food Standards Code, and I will also
†††††† discuss the definition of gluten found in Clause 1
†††††† of that same standard.
†††††††††††††††† MS. KANE:† The current Codex standard that
†††††† is in effect today defines "gluten" as "Those
†††††† proteins commonly found in wheat, triticale, rye,
†††††† barley or oats to which some persons are
†††††††††††††††† The current standard further defined the
†††††† term "gluten-free" to mean that "The total nitrogen
†††††† content of gluten-containing cereal grains used in
†††††† the product does not exceed 0.5 gram nitrogen per
†††††† 100 grams of the cereal grains on a dry weight
†††††††††††††††† MS. KANE:† The current standard states
†††††† that it does not apply to foods which in their
†††††† normal form do not contain gluten.† Gluten-free
†††††† foods are defined according to two categories,
†††††† those that contain the cereal ingredients -- wheat,
†††††† triticale, rye, barley or oats or their
†††††† constituents, which have been rendered gluten-free
††† †††-- or those foods in which any ingredients normally
†††††† present that contain gluten have been substituted
†††††† by other ingredients that do not contain gluten.
†††††††††††††††† MS. KANE:† In comparison, the Codex
††† †††Proposed Draft Revised Standard for Gluten-Free
†††††† Foods at Step 7 defines "gluten" to be "The protein
†††††† fraction from wheat, rye, barley oats or their
†††††† crossbred varieties and derivatives to which some
†††††† persons are intolerant and that is insoluble in
†††††† water and 0.5 molar solution of sodium chloride."
†††††††††††††††† You will see that in this definition and
†††††† in others that are occurring in the proposed
†††††† standard information within brackets is intended to
†††††† indicate that that information is
†††††† additional discussion at the Codex Nutrition
†††††† Committee.† Their next session meets in November
†††††††††††† ††††The Proposed Standard also defines the
†††††† term "Prolamin" to mean "The fraction from gluten
†††††† that can be extracted by 40 to 70 percent aqueous
†††††† ethanol."† This definition specifically identifies
†††††† the prolamins: gliadin from wheat, secalin from
†††††† rye, hordein from barley, and avenin from oats.
†††††††††††††††† MS. KANE:† The Proposed Standard also
†††††† states that it applies to those foodstuffs and
†††††† ingredients which have been especially processed or
†††††† prepared to meet the dietary needs of persons
†††††† intolerant to gluten.
†††††††††††††††† Therefore, this parameter is similar to
†††††† the one for the current standard in that neither of
†††††† the two standards, the current and the proposed,
†††††† would include foods that are naturally or
†††††† inherently free of gluten.
†††††††††††††††† The proposed standard also identifies
categories of gluten-free foods where their
†††††† definitions specify certain limits on their gluten
†††††††††††††††† MS. KANE:† In the first proposed category,
†††††† gluten-free foods consisting of ingredients which
†††††† do not contain any prolamins from wheat or all
†††††† Triticum species -- rye, barley, oats -- or their
†††††† crossbred varieties cannot have a gluten level that
†††††† exceeds 20 parts per million.† Again, you will see
†††††† that "20 parts per million" is within brackets,
†††††† therefore, this number is pending.
†††††††††††††††† MS. KANE:† This proposed definition also
†††††† specifically cites three examples of grains within
†††††† different species of Triticum, they are: spelt,
†††††† kamut, and durum wheat.
†††††††††††††††† Although triticale is not one of the
†††††† grains that is identified within the definition by
†††††† its name, it is included because it is a crossbred
†††††† hybrid of wheat and rye.
†††††††††††††††† In the second proposed category of
foods, they are those consisting of
†††††† ingredients from wheat, rye, barley, oats, spelt or
†††††† their crossbred varieties that have been rendered
†††††† gluten-free and cannot have a gluten level that
†††††† exceeds 200 parts per million.† Again, "200 parts
†††††† per million" is cited in brackets, and it is
†††††† therefore pending.
†††††††††††††††† MS. KANE:† In the third proposed category,
†††††† gluten-free foods consisting of any mixture of the
†††††† ingredients as described in the previous two
†††††† categories, cannot have a gluten level that exceeds
†††††† 200 parts per million.† Again, "200 parts per
†††††† million" is cited in brackets and it is pending.
†††††††††††††††† MS. KANE:† Based upon my reading of the
†††††† session reports for the Codex Nutrition Committee
†††††† and related documents, it appears that the
†††††† rationale for including two levels, the 20 and 200
†††††† parts per million, in the definition of gluten-free
†††††† foods was to accommodate different points of view
†††††† of the Codex member countries that thought there
†††††† should be a
different level of gluten based upon
†††††† their experience with their populations, what would
†††††† be adequately protective.
†††††††††††††††† There were some countries that believed
†††††† either the lowest limits of detection or 20 parts
†††††† per million would be most protective of those that
†††††† are very sensitive to gluten.
†††††††††††††††† Twenty parts per million was considered a
††††† †practical limit to make it more feasible for
†††††† industry to produce gluten-free foods in that
†††††††††††††††† Other countries believed that the higher
†††††† level of 200 parts per million would be
†††††† appropriate, because they had experiences with
†††††† citizens in their country that had celiac disease
†††††† where they had been consuming wheat-starch-based
†††††† products for years without harm, and they enjoyed
†††††††††††††††† The 20 parts per million level would
†††††† essentially prohibit the inclusion of those
†††††† wheat-starch-based products.† Therefore, it was a
†††††† compromise, the low limit and the high limit, and
realized they could create some confusion on
†††††† the part of the consumer.
†††††††††††††††† I also want to point out that the proposed
†††††† definition of gluten-free foods specifically cites
†††††† that whatever detection method is used it should
†††††† have a detection limit of at least 10 parts per
†††††† million gluten in the product on a dry weight
†††††††††††††††† MS. KANE:† The next definition I will
†††††† discuss is that found in Canada's Food and Drug
†††††† Regulations at Section B.24.018, and it states:
†††††† "No person shall label, package, sell or advertise
†††††† a food in a manner likely to create an impression
†††††† that is a gluten-free food unless the food does not
†††††† contain wheat, including spelt and kamut, or oats,
†††††† barley, rye, triticale or any part thereof."
†††††††††††††††† MS. KANE:† Canada's definition of
†††††† gluten-free prohibits the use of derivatives or
†††††† constituents of any of the cited grains.
†††††† Therefore, wheat starch would not be allowed in a
that was labeled gluten-free.
†††††††††††††††† It is my understanding based upon
†††††† communication with staff who work with Health
†††††† Canada and the Canadian Food Inspection Agency,
†††††† that the definition that Canada is using was
†††††† developed using a rule-making process, but they
†††††† closely coordinated with the Canadian Celiac
†††††† Association in the parameters for this definition.
†††††††††††††††† Canada underwent a rule-making process
†††††† similar to the one that we use in the United States
†††††† where they reviewed the relevant scientific
†††††† literature, they published a proposed rule,
†††††† considered comments before it went final, and they
†††††† determined that back in the mid-1990s that there
†††††† was insignificant or insufficient I should say
†††††† scientific evidence to support establishing a level
†††††† that would be safe for all celiac patients.
†††††††††††††††† MS. KANE:† In the last definitions of
†††††† gluten-free that I will be discussing, in the
†††††† Australia New Zealand Food Standards Code, first,
†††††† in Clause 1 of Standard 1.2.8 of the "Code," which
†††††† I will
refer to simply as that rather than
†††††† repeating that long name, it defines "gluten" as
†††††† "'The main protein in wheat, oats, barley,
†††††† triticale and spelt relevant to the medical
†††††† conditions, Coealic disease and dermatitis
†††††††††††††††† It also defines in Clause 16 of that same
†††††† standard the terms "gluten-free" and "low gluten."
†††††††††††††††† MS. KANE:† "Gluten-free" is defined as
†††††† those foods that contain no detectable amount of
†††††† gluten.† They also cannot contain any oats or their
†††††† products or any cereals containing gluten that had
†††††† been malted or their products.† It has to meet all
†††††† of those three criteria not just one.
†††††††††††††††† In addition, their Code defines the term
†††††† "low-gluten foods" to mean those that contain no
†††††† more than 20 milligrams of gluten per 100 grams of
†††††† food.† Now, although not stated in the Code as
†††††† such, this level of gluten is equivalent to 200
†††††† parts per million.
MS. KANE:† It is my understanding
†††††† upon communication with Food Standards Australia
†††††† New Zealand's staff that they also underwent a
†††††† rule-making process where they proposed these
†††††† definitions for "gluten-free" and "low-gluten"
†††††† before they went final.
†††††††††††††††† They did a review of the relevant
†††††† scientific literature.† They considered public
†††††† comment, and they also consulted with experts in
†††††† the appropriate fields to develop the definitions
†††††† that are in effect today.
†††††††††††††††† In addition, the fair trading laws in both
†††††† Australia and New Zealand were interpreted as
†††††† prohibiting the term "gluten-free" from being used
†††††† with any foods that contained any detectible amount
†††††† of gluten.
†††††††††††††††† MS. KANE:† Further, the definition of
†††††† gluten-free was influenced by a lack of reliable
†††††† analytical methods to detect gluten in oats and
†††††† malted cereals.† Essentially, their definition says
†††††† not only no detectible amount of gluten, but no
†††††† oats or
other products, no malted cereals
†††††† containing gluten and their products because of
†††††† this limitation of analytical methods.
†††††††††††††††† MS. KANE:† The Code includes two
†††††† definitions, "gluten-free" and "low gluten," to
†††††† provide citizens who have celiac disease a choice
†††††† between which level of gluten-containing foods they
†††††† want to consume based upon their individual gluten
†††††† tolerance level and the advice of their healthcare
†††††††††† ††††††In closing, I would like to sincerely
†††††† thank the staff that I consulted with at Health
†††††† Canada, and the Canadian Food Inspection Agency, as
†††††† well as Food Standards Australia and New Zealand.
†††††††††††††††† With that, I will take any questions.
†††††††††††††††† CHAIRMAN DURST:† Thank you very much.
†††††††††††††††††††††† QUESTION AND ANSWER SESSION
†††††††††††††††† CHAIRMAN DURST:† Does the Committee have a
†††††† question or comment?
††††††††††††† †††DR. BRITTAIN:† Erica Brittain.† I guess I
†††††† find it
appealing the idea of the two levels, just
†††††† as a comment, in the last one you cited.† This
†††††† might be applicable to the allergy situation as
†††††††††††††††† CHAIRMAN DURST:† Okay.† Anything else?
†††††††††††††††† DR. NELSON:† Mark Nelson.† Did your
†††††† contacts in Australia, New Zealand and Canada give
†††††† any indication that they might change their
†††††† definitions or their categorizations if there were
†††††† more work done on thresholds, if that data based
†††††††††††††††† MS. KANE:† That sort of conversation
†††††† didn't occur between me and them, but I would think
†††††† because they are government agencies, just like FDA
†††††† is, if there were newer information on the horizon,
†††††† they would probably consider it.† Whether they
†††††† would go through the rule-making process and change
†††††† it, I guess they would base it on the needs of
†††††† their own populations.
†††††††††††††††† DR. NELSON:† I guess the opportunity for
†††††† -- this is Mark Nelson again -- two categories does
†††††† have some
attractiveness.† I guess at Codex it is
†††††† going to be gluten-free and really gluten-free.
†††††††††††††††† (General laughter.)
†††††††††††††††† CHAIRMAN DURST:† Suzanne.
†††††††††††††††† DR. TEUBER:† Suzanne Teuber.† To your
†††††† knowledge in talking with these folks, have their
†††††† been any consumer-preference studies or behavior
†††††† studies completed or underway with how the celiac
†††††† disease patient is using these standards in terms
†††† ††of their overall intake?
†††††††††††††††† MS. KANE:† I don't have personal knowledge
†††††† of that.† However, the Canadian Celiac Association
†††††† is very supportive of Canada's definition of
†††††† gluten-free.† Because they were instrumental in
†††††† helping develop it, so they were very supportive of
†††††††††††††††† CHAIRMAN DURST:† Yes.
†††††††††††††††† DR. McBRIDE:† Margaret McBride.† Do I
†††††† understand from your slides about the Codex
†††††† proposed changes that the term "gluten-free" would
†††††† be applied both to those foods that contained none
†††††† of the products in question and are lower than 20
†††††† parts per
million, and to those foods that are
†††††† wheat-based and gluten has been removed but would
†††††† contain up to 200 parts per million?† I realize the
†††††† numbers are in question.
†††††††††††††††† MS. KANE:† Right.† They do not apply to
†††††† the term.† They don't want the term "gluten-free"
†††††† to apply to naturally gluten-free foods but those
†††††† that have been specially processed or prepared
†††††† where the formulation has been controlled.
†††††††††††††††† There is a substitution of ingredients or
†††††† a removal of gluten from ingredients.† It would
†††††† cover categories that are wheat-starch-based.† That
†††††† is where the 200 parts per million definition is
†††††† coming into play.
†††††††††††††††† Member countries did not want
†††††† wheat-starch-based products to be excluded from
†††††† being called gluten-free, if there was only one
†††††† definition of 20 parts per million.† That is why
†††††† they compromised and had the two levels that would
†††††††††††††††† DR. McBRIDE:† A follow-up.† Would I assume
†††††† that they would then be called something different,
†††††† or would we
be expecting the consumer --
†††††††††††††††† (Simultaneous discussion.)
††† †††††††††††††MS. KANE:† No.† Right now, as it stands,
†††††† they are saying one definition "gluten-free" to
†††††† apply to three categories of gluten-free.† However,
†††††† that could change.
††††††††††††††††††††††††††††††† Now, keep in mind all of this
†††††† is pending.† It is at Step 7 of an 8-step process.
†††††† I know there is a Working Group, the Prolamin
†††††† Analysis and Toxicity Group.† That information will
†††††† come into play.† These levels are not definite and
†††††† they could change.
†††††††††††††††† If both of those situations or all three
†††††† were called gluten-free, then we would have to
†††††† expect that the consumer who felt that they were
†††††† very sensitive and wanted truly a very low level,
†††††† below 20 parts per million, would have to read and
†††††† understand the names for the various grains,
†††††† et cetera, that would be on the ones where in fact
†††††† products that at least one time had contained
†††††† gluten were used.
†††††††††††††††† I understand that, and the report I cited
†††††† on my
second slide, the "ALINORM Report" is the
†††††† latest one, to my knowledge, that contains the
†††††† language of the current proposed standard at
†††††† Step 7.† It doesn't go into those details about how
†††††† it might be labeled alternatively or what
†††††† additional information it would include.† You're
†††††† right, it does create confusion.† How would you
†††††† know if it is 20 parts?† How would you know if it
†††††† is 200 parts?
†††††††††††††††† That issue was brought up in some related
†††††† documents, but it is not found in the latest
†††††† session report.† However, you're absolutely right.
†††††††††††††††† DR. NELSON:† This is Mark Nelson.† I just
†††††† want to address that question about the Codex
†††††† label.† There is a separate committee, Codex
†††††† Committee on Food Labeling, and these definitions I
†††††† would expect would ultimately be referred to the
†††††† Codex Committee on Labeling to address the issue
†††††† you have just raised about the potential confusion.
†††††††††††††††† CHAIRMAN DURST:† Suzanne.
†††††††††††††††† DR. TEUBER:† Suzanne Teuber.† I also see
†††††† an issue about cross-contamination problems with
†††††† foods that
you wouldn't expect to contain gluten
†††††† and yet might contain contaminants because some of
†††††† these, the rules that you are talking about, really
†††††† don't address that.
†††††††††††††††† Do you have any information on that, like
†††††† say, corn that may be processed in a place that
†††††† also has processed wheat?† It really would be
†††††† beneficial to the consumer if it were to undergo
†††††† testing and have a specific label, and yet these
†††††† other definitions in other countries don't seem to
†††††† cover that all.† It would probably just come out
†††††† with no statement.† Is that a correct
†††††††††††††††† Or, actually maybe, Dr. Nelson--?
†††††††††††††††† DR. NELSON:† I think in Europe and Codex
†††††† also has a standard for good manufacturing
†††††† practices; the Europeans have the equivalent.† I
†††††† think the issue there would be the responsibility
†††††† of the manufacturer to maintain good manufacturing
†††††† practices and prevent as much possible that cross
†††††††††††††††† CHAIRMAN DURST:† Marc.
DR. SILVERSTEIN:† Marc
†††††† you clarify the categories of foods to which this
†††††† would apply?† I would like you to, because I'm not
†††††† sure I understood the criteria exactly.† If a food
†††††† has multiple ingredients, does this apply to all of
†††††† the ingredients in the food?
†††††††††††††††† This is packaged and labeled food.† One or
†††††† the major ingredient may be a food which in its
†††††† normal form does not contain gluten, yet there
†††††† might be other ingredients perhaps mixed in with it
†††††† that would.
†††††††††††††††† Would it be that it applies to a labeled
†††††† package food which any of the ingredients contain
†††††† gluten, or would it be just the major ingredient
†††††† does not contain gluten and there might be some
†††††† additive or some other component ingredient?
†††††††††††††††† MS. KANE:† It is my understanding it would
†††††† apply to all ingredients.† It would be selectively.
†††††† If a packaged food that is labeled gluten-free, it
†††††† would have to conform to the proposed.† Of course,
†††††† again, it is proposed so it is not a done deal.
†††††† However, there are categories going back.
Can we go back?† Can you reverse
†††††† It is probably more towards the front.† Okay, that
†††††† one right there.
†††††††††††††††† MS. KANE:† That is the first category
†††††† consisting of ingredients.† It doesn't say primary
†††††† ingredients.† It means ingredients.† That is how I
†††††† understand it.† Keep in mind I've never been a
†††††† member of the U.S. delegation to a Codex Committee
†††††† meeting.† I do not have firsthand knowledge of the
†††††† discussions.† It is only based on my reading of
†††††† their session reports and related documents.† The
†††††† way that is written I would interpret that to mean
†††††† all ingredients.† Maybe someone who has attended
†† ††††the Codex could speak to that?
†††††††††††††††† CHAIRMAN DURST:† Mark.
†††††††††††††††† DR. NELSON:† Mark Nelson.† I think
†††††† everybody would interpret that as all ingredients
†††††† not just the main ingredients but including the
†††††† minor ingredients, flavors, spices, and so on.
†††††††††††††††† I can just talk a little bit about my
†††††† experience in the food industry.† I have worked
†††††† both for
packaged goods companies but also
†††††† suppliers to packaged goods companies.
†††††††††††††††† They look at it very carefully to find out
†††††† what the subingredients might be in, say, flavors
†††††† or an additive or carriers or something like that.
†††††† I can assure you, being a supplier to companies
†††††† like Nestle or Kellogg's or Kraft, we have to
†††††† provide a fairly substantial dossier to them for
†††††† every ingredient we supply them to deal with issues
†††††† like allergens and gluten levels as well.† The food
†††††† industry itself does take this very seriously.
†††††††††††††††† CHAIRMAN DURST:† Soheila.
†††††††††††††††† DR. MALEKI:† Soheila Maleki.† I guess this
†††††† is more a question.† It seems to me that based on
†††††† what we have seen on some of the slides you've
†††††† shown today that there really isn't good analytical
†††††† method to be able to determine.
†††††††††††††††† For example, the nitrogen content, you
†††††† could measure every protein in there and you could
†† ††††weigh overestimate the amount of gluten.† Measuring
†††††† gluten in the insoluble water fraction, that seems
†††††† to be, again, if you can solubilize it.† If you
really detect it, okay.
†††††††††††††††† DR. NELSON:† I'm sorry, you may have to
†††††† start over.† Sorry about that.
†††††††††††††††† (General laughter.)
†††††††††††††††† DR. MALEKI:† It is kind of a question.
†††††† Based on this, I don't think there is really an
†††††† analytical method that can make you comply to this,
†††††† so how does this work?† How are they going to
†††††† enforce it?
†††††††††††††††† MS. KANE:† Keep in mind that the nitrogen
†††††† definition of gluten is the current one.† They are
†††††† proposing it be defined as the protein fraction for
†††††† wheat, rye, barley, et cetera, to which persons are
†††††† intolerant and it is insoluble in water and a
†††††† 0.5 molar solution to sodium chloride.
†††††††††††††††† However, there is an analytical method
†††††† component of a standard, and that is pending
†††††† because they were talking about the R5 Mendez
†††††† method, ELISA.† They knew that they would have to
†††††† have a method that was sensitive enough, reliable,
†††††† accurate and would detect the types of proteins
†††††† that they are talking about in their definition.
That is going to be, I'm assuming, part of
†††††† the discussion at the next Codex meeting is to
†††††† bring that information about the methodology into
†††††† play, because those were the two components, the
†††††† methodology and threshold levels.† Those are the
†††††† two areas needed to be worked out, and so I think
†††††† that is going to be the crux of the discussion at
†††††† the next Codex meeting.
†††††††††††††††† DR. MALEKI:† I just wanted to make a
†††††† comment as a follow-up.
†††††††††††††††† CHAIRMAN DURST:† Oh, okay.
††††††††††††† †††DR. MALEKI:† I'm Soheila Maleki.† It seems
†††††† like the antibodies, the R5 kit again doesn't
†††††† detect gluten it detects gliadin.† Maybe Steve can
†††††† help with that somewhere along the line.
†††††††††††††††† All right, go ahead.
††††††† †††††††††DR. CALLERY:† Pat Callery.† If the
†††††† analytical part can be worked out, which I think it
†††††† can.† I wonder if there is an analogy here with
†††††† caffeine where we have caffeine-free sodas and
†††††† such, which we expect to have no caffeine, and
†††††† coffee that is decaffeinated that does have
†††††† caffeine in
it.† The word is not very pretty,
†††††††††††††††† There may be an analogy that says when it
†††††† is gluten-free it is truly gluten-free and when it